MANUAL  OF  VITAL  FUNCTION 

TESTING  METHODS  AND 

THEIR  INTERPRETATION 


WILFRED  M.  BARTON 


!TY  OF  CALIFORNIA 


Manual  of  Vital  Function 

Testing  Methods  and 

Their  Interpretation 


BY 

WILFRED  M.  BARTON,  M.D. 

A  ssociate  Professor  of  Medicine,  Medical  Department,  Georgetown 
University,  Attending  Physician  to  Georgetown 
University  Hospital  andW asking- 
ton  A  sylum  Hospital 


BOSTON:    RICHARD    G.  BADGER 
TORONTO:    THE  COPP  CLARK  CO.,  LIMITED 


Copyright,  1916,  by  Richard  G.  Badger 
All  Rights  Reserved 


THE  GORHAM  PRESS,  BOSTON,  U.  S.  A. 


TO  DE.  GEORGE  M.  KOBER,  DEAN  OF  THE 
GEORGETOWN  MEDICAL  SCHOOL,  THIS  LITTLE 
BOOK  IS  DEDICATED,  AS  A  MODEST  TOKEN  OF 
APPRECIATION  OF  HIS  UNSELFISH  DEVOTION  TO 
OUR  SCHOOL  AND  HOSPITAL 


PREFACE 

THERE  should  always  be  some  valid  reason  for  writing 
a  new  book,  especially  a  medical  book.  My  reason  for 
writing,  or  perhaps  to  express  it  more  accurately,  for 
compiling  this  work,  is,  that  the  information  that  it 
contains  is  scattered  quite  broadly  thro  a  wide  and 
extensive  medical  literature,  that  may  not  be  readily 
accessible  to  all,  and  which  has  never,  so  far  as  I  know, 
been  collected  together  in  book  form. 

Inasmuch  as  every  progressive  physician  and  sur- 
geon at  the  present  day  is  making  more  or  less  frequent 
use  of  the  different  functional  tests,  to  determine  the 
efficiency  of  vital  organs,  it  occurred  to  me  that  to 
collect  them  all  in  one  volume,  together  with  the  neces- 
sary data  whereby  they  might  be  intelligibly  inter- 
preted, might  prove  to  be  useful,  particularly  to  the 
busy  practitioner. 

The  following  work,  which  is  an  effort  to  carry  out 
that  idea,  includes  only  the  tests  for  so  called  vital 
functions,  namely  those  applied  to  the  liver,  kidneys, 
heart,  pancreas,  and  ductless  glands.  To  go  beyond 
this  and  take  up  the  functional  tests  of  all  the  organs, 
such  as  the  eye,  ear,  nervous  system,  etc.,  would  be  to 
exceed  the  legitimate  field  of  true  function  testing  and 
to  encroach  upon  the  well-trodden  fields  of  general 
semiology  and  diagnosis. 

I  hope  the  book  may  prove  to  be  useful  and  con- 
venient to  all  who  are  interested  in  this  fascinating  and 
ever-developing  field  of  clinical  pathology. 

5 


6  Preface 

It  is  a  matter  of  which  American  physicians  may 
well  be  proud  that  the  most  substantial  and  brilliant 
progress  in  the  development  of  tests  of  organic  func- 
tion, particularly  in  reference  to  the  kidneys  and  liver, 
has  been  brought  about  by  the  assiduous  efforts  of  some 
of  their  own  fellow  countrymen. 

In  the  chapter  on  heart  I  have  received  valued  assist- 
ance from  my  friend  and  colleague,  Dr.  Thos.  S.  Lee. 


CONTENTS 

TESTS  OF  LIVER  FUNCTION 

PAGE 

GENERAL  CONSIDERATIONS 13 

FUNCTIONAL  TESTS  TO  DISCOVER  DISTURBANCES  OF  THE  GLYCO- 

GENIC  FUNCTION  OF  THE  LIVER 14 

The  Cane  Sugar  Test 15 

The  Glucose  Test 16 

The  Levulose  Test 16 

The  Galactose  Test 18 

Conclusions   Concerning  the   Carbohydrate   or  Sugar 

Tests 18 

FUNCTIONAL  TESTS  TO  DETERMINE  DISTURBANCE  OF  THE  UREA- 
GENETIC  FUNCTION  OF  THE  LIVER 20 

Urea  Elimination  and  Nitrogen  Coefficient  as  Criteria  of 

Liver  Function 22 

Quantitative  Urea    Estimation  in  Urine    (Marshall's 

Method} 24 

Total    Nitrogen    Estimation    in    Urine      (Kjeldahl's 

Method) 28 

Augmentation  of  Urinary  Ammonia  as  an  Index  of  Urea- 
genetic  Liver  Function 30 

Estimation    of    Ammonia    Nitrogen    in    Urine    (The 

Formalin  Method) 31 

Experimental  Provocative  Ammoniuria 32 

Aminoaciduria  as  a  Criterion  of  Liver  Function   ....       33 
Experimental  Provocative  Aminoaciduria     ....       33 
Estimation  of  Residual  Nitrogen  in  Blood  Serum  as  an 

Index  of  Hepatic  Function 34 

Summary  of  the  Value  of  Ureagenetic  Tests  of  Liver 
Function 35 

FUNCTIONAL  TESTS  TO  DETERMINE  DISTURBANCE  OF  THE  ANTI- 
TOXIC FUNCTION  OF  THE  LIVER 36 

Methylene  Blue  Test  of  Toxopexic  Function  of  the  Liver 

(Chauffard-Castaigne  Test) 36 

Roche's  modification  of  Methylene  Blue  Test    ...       37 
Indicanuria,   Spontaneous  and   Provocative  as   Means  of 

Testing  Integrity  of  Hepatic  Fixation 38 

Tests  for  Urinary  Indican 38 

7 


8  Contents 

PAGE 

FUNCTIONAL  TESTS  TO  DETERMINE  DISTURBANCE  OF  THE  SAN- 

GUINOPOIETIC  FUNCTION  OF  THE  LIVER 40 

Estimation  of  Blood  Coagulation  Time  as  an  Index  of  Liver 

Function.     Wright's  Method  of  Fixing  Coagulation  Time      41 
The  Fibrinogen  Test  of  Whipple  and  Horwitz     ....       42 
Estimation  of  Fibrinolysis  Time  as  an  Index  of  Liver  Func- 
tion (Goodpasture' s  Test) 43 

Estimation  of  Lipase  in  the  Blood  as  an  Index  of  Liver 

Function  (Whipple's  Test) 44 

Lowenhart's  Methods  of  Lipase  Estimation       ...       45 

Ghedini's  Test    ....  46 

Application  of  Abderhalden's  Method  to  Estimation  of 
Sanguinopoietic  Liver  Function 46 

FUNCTIONAL  TESTS  TO  DETERMINE  DISTURBANCE  OF  THE  EXOCRIN- 

ous  OR  BILIARY  FUNCTION  OF  THE  LIVER 47 

Tests  for  Urobilinogen,  Urobilin  and  Bilirubin  in  the  Urine. 

Interpretation   of   Results   with   Reference   to   Hepatic 

Function.     The  Urobilinogen  Test  (Ehrlich's  Test)     .      .       51 

Tests  for  Urobilin 54 

Tests  to  Determine  the  Global  capacity  of  the  Liver  to 

Eliminate  Foreign  Substances 55 

Phenoltetrachlorphthalein  Test  of  Liver  Function  (Rown- 

tree,  Horwitz  and  Bloomfield  Test) 55 

TESTS  OF  KIDNEY  FUNCTION 

GENERAL  CONSIDERATIONS 64 

URINALYSIS  AS  A  CRITERION  OF  RENAL  FUNCTION      ....       70 
Estimation    of    Urinary    Water.     Experimental    Polyuria 

(Albarran's  Method) 72 

The  Water  Tests  (Straus-Grunwald  Method) 75 

The  Diuretic  Tests  (Pharmacological) 75 

Estimation  of  Sodium  Chloride  as  an  Index  of  Renal  Func- 
tion   76 

The    Sodium    Chloride    Test.     Test    of    Alimentary 

Chloruria 79 

Sodium  Chloride  Estimation 79 

Estimation  of  Urinary  Nitrogen  as  an  Index  of  Renal  Func- 
tion   80 

Diminished  and  Delayed  Excretion  of  Urea   ....       82 
Forced  Urea  Elimination.     Provocative  Urea  Test  of 

McKaskey 83 

Estimation  of  Urinary  Coloring  Matter  as  an  Index  of 

Renal  Function 84 

Estimation  of  Urinary  Diastase  as  an  Index  of  Renal  Func- 
tion .       85 


Contents  9 

PAGE 

STUDY  OF  THE  PHYSICAL  AND  BIOLOGICAL  CHARACTERISTICS  OF 

THE  URINE  AS  CRITERIA  OF  KIDNEY  FUNCTION       ....  86 
Estimation   of  Freezing   Point   of   Urine   (Cryoscopy)    as 

Index  of  Renal  Function  (v.  Koranyi's  Test}     ....  86 
Electrical  conductivity  of  the  Urine  as  Index  of  Renal 

Function 89 

Estimation  of  Urinary  Toxicity  as  Index  of  Renal  Function  89 

STUDIES  OF  THE  BLOOD  AS  CRITERIA  OF  RENAL  FUNCTION  .      .  90 
Urea  and  Incoagulable  or  Rest  Nitrogen  in  the  Blood  as 

Indexes  of  Renal  Function 90 

Marshall's  Method  for  Determination  of  Urea  in  Blood       .  94 
Estimation  of  Incoagulable  Nitrogen.     Morris'  Modifica- 
tion of  Hohlveg-Meyer  Method;  Folin  and  Denis  Method  99 
Estimation  of  Blood  Coagulation  Time  as  Index  of  Renal 

Function 104 

Cryoscopy  of  Blood  as  Index  of  Renal  Function   ....  104 

STUDIES  OF  THE  ELIMINATION  OF  FOREIGN  SUBSTANCES,  BY  THE 

KIDNEY  AS  CRITERIA  OF  RENAL  FUNCTION 105 

1.  Miscellaneous  Substances: 

The  Potassium  Iodide  Test 105 

The  Phloridzin  Test 107 

The  Hippuric  Acid  Test 108 

The  Lactose  Test 108 

2.  Elimination  of  Dyes — Urinary  Chromoscopy.      .      .      .  110 

The  Methylene  Blue  Test Ill 

The  Indigo  Carmine  Test 114 

The  Phenolsulphonephthalein  Test  of  Rowntree  and 

Geraghty 115 

GENERAL  SUMMARY  OF  RENAL  FUNCTION  TESTS 128 

SELECTION  AND  PRACTICABILITY  OF  RENAL  FUNCTION  TESTS     .      .  138 

TESTS  OF  PANCREATIC  FUNCTION 

GENERAL  CONSIDERATIONS 142 

TESTS  OF  PANCREATIC  FUNCTION  WHICH  CONCERN  THE  EXTERNAL 

OR  DIGESTIVE  ACTIVITY  OF  THE  ORGAN 144 

Proteid  Digestion  Tests:     Estimation  of  Undigested  Protein 
in  Stool  as  Means  of  Determining  Pancreatic  Hypofunc- 

tion 146 

Schmidt's  Cell  Nuclei  Test 148 

Sahli's  Glutoid  Capsule  Test 148 

FAT  DIGESTION  TESTS.    DETERMINATION  OF  EXCESS  OF  FAT  IN 

THE  STOOLS 150 


10  Contents 

PAGE 

STARCH  DIGESTION  TESTS 153 

IDENTIFICATION  OF  FERMENTS  IN  EXCRETA  AS  EVIDENCE  OF  PAN- 
CREATIC FUNCTION 153 

Demonstration  of  Trypsin  in  Stools 154 

Demonstration  of  Trypsin  in  Stomach  Contents       .      .      .  156 

Demonstration  of  Diastase  in  Feces 158 

Demonstration  of  Lipase  in  Stools 160 

TESTS  FOR  PANCREATIC  FUNCTION  WHICH  CONCERN  THE  INTERNAL 

OR  METABOLIC  FUNCTION  OF  THE  ORGAN 161 

The  Cammidge  Reaction 162 

Loewi's  Pupillary  Test 165 

Spontaneous  and  Provocative  Glycosuria 166 

GENERAL  CONCLUSIONS  CONCERNING  PANCREATIC  INSUFFICIENCY 

TESTS 167 

TESTS  OF  HEART  FUNCTION 

GENERAL  CONSIDERATIONS 168 

Reaction  and  Muscular  Exertion  as  Basis  for  Estimating 

Cardiac  Function 171 

The  Staircase  Case  (Selig's  Test) 173 

The  Ergometer  Test  (Graupner's  Test) 175 

Mendelsohn's  Test 179 

Katzenstein's  Test 181 

Herz's  Self-Checking  Test 183 

Gymnastic  Resistance  Test 184 

The  Russian  Test 185 

The  Venous  Pressure  Test  (Schott's  Test)      ....  185 

Cardiac  Reflex  Estimations  in  Determining  Heart  Function  187 

Sodium  Chloride  Elimination  and  Cardiac  Function     .      .  188 
Modern   Clinical   and   Instrumental   Methods   in   Cardio- 
Pathology;  Their  Applicability  to  Estimation  of  Heart 

Function 188 

Sphygmomanometry.     Work- Velocity  Ratio      .      .      .  188 

Cardiac  Efficiency  Factor  of  Tigerstedt 193 

Cardiac  Strength,  Cardiac  Weakness  Ratio  .      .      .      .194 

Cardiac  Overload  Factor  of  Stone 197 

Reontgenoscopy  and  Cardiac  Function 199 

Sphygmography  and  Cardiac  Function 199 

GENERAL  CONCLUSIONS  AS  TO  TESTS  OF  CARDIAC  FUNCTION     .      .  202 

TESTS  OF  DUCTLESS  GLAND  FUNCTION 

GENERAL  CONSIDERATIONS 240 

The  Thyroid  Gland 270 


Contents 

HYPERFUNCTION  OF  THYROID  GLAND 

Hypophysis-Extract  Test  of  Claude,  Baudouin  and  Porak 

Adrenalin-Mydriasis  Test  of  Loewi 

Experimental  Hyperthyroidism  Test 

Aceto-nitril  Test  of  Reid  Hunt 

Metabolic  Tests  of  Hyperthyroidism 

Complement-Deviation  Test  of  Hyperthyroidism 
Abderhalden  Test  in  Hyperthyroidism 

HYPOFUNCTION  OF  THYROID  GLAND 

Therapeutic  Test  of  Hypof  unction 

The  Parathyroid  Glands 

The  Thyrnus  Gland 

The  Suprarenal  Glands 

HYPOFTTNCTION  OF  SUPRARENAL  GLANDS 

Sugar  Tolerance  and  Hypoadrenal  Function  .... 

HYPERFUNCTION  OF  SUPRARENAL  GLANDS 

Adrenalinemia  and  Hyperadrenalism 

Adrenalin  Glycosuria  and  Hyperfunction        .... 

Complement-fixation  in  Suprarenal  Disease    .... 

The  Hypophysis 


STATES  OF  HYPERPITUITARISM 246 

Increased  Gas  Exchange  and  Hyperpituitarism   ....  247 

Glycosuria  and  Hyperpituitarism 248 

STATES  OF  HYPOPITUITARISM 249 

INDEX  .  251 


MANUAL  OF  VITAL  FUNCTION 
TESTING  METHODS 

CHAPTER  I 
TESTS  OF  LIVER  FUNCTION 

GENERAL    CONSIDERATIONS 

THE  liver  cell  represents  the  whole  organ  in  minia- 
ture. If  we  possessed  an  adequate  knowledge  of  all 
the  functions  of  this  cell,  we  would  understand  com- 
pletely the  functions  of  the  organ. 

The  functions  of  the  liver  cell  are  numerous  and  each 
individual  cell  performs  its  quantitative  quota  of  all 
these  functions.  The  liver  is  provided  with  two  evacu- 
ating channels,  one  internal,  by  way  of  the  blood  (he- 
patic vein),  the  other  external,  by  way  of  the  biliary 
passages.  It  receives  blood  by  way  of  the  portal  vein 
from  the  digestive  tract  and  its  related  organs,  and  dis- 
charges into  the  duodenum  its  more  or  less  complex 
excretion. 

Regarded  as  a  center  of  elaboration,  the  liver  cell 
has  several  important  functions,  chief  of  which  are: 
1.  ureagenetic,  2.  glycogenetic,  3.  lipasic,  4.  antitoxic  or 
cytopexic,  5.  sanguinopoietic,  6.  thermic,  7.  ferric. 
The  above  mentioned  functions  are  spoken  of  as  en- 
docrinous.  The  liver  has,  however,  an  exocrinous  func- 
tion which  by  some  is  regarded  as  the  most  character- 
istic, namely,  the  excretion  of  bile  by  way  of  the  biliary 
passages. 

Tests  of  hepatic  function  are  directed  towards  the  de- 
termination of  the  integrity  of  one  or  the  other  of 
these  phases  of  activity. 

13 


14      Manual  of  Vital  Function  Testing  Methods 

There  is  no  organ  whose  functional  and  clinical  ex- 
amination is  fraught  with  more  difficulties  than  the  liver. 
Slight  functional  disturbances  of  the  organ  are  attended 
by  very  uncertain  symptomatology.  When  severe  or- 
ganic lesions  exist,  such  as  acute  yellow  atrophy,  cirrho- 
sis, abscess,  cancer,  etc.,  modifications  in  the  size  of 
the  liver,  as  well  as  its  consistence,  together  with 
symptoms  of  portal  hypertension  (ascites)  and  of  bili- 
ary obstruction  (icterus),  offer  a  combination  of  objec- 
tive evidence  which  makes  the  diagnosis  usually  clear. 

But  there  is  a  longer  or  shorter  period  in  all  these 
diseases,  usually  in  the  earlier  stages  during  which  a 
condition  of  hepatic  insufficiency  (hypohepatism)  and 
more  rarely,  hepatic  hyper  function  (hyperhepatism) 
exists,  which  might  be  recognized  by  appropriate  tests. 
The  trend  of  modern  investigation  is  in  the  direction 
of  the  development  of  practical  functional  tests  of 
sufficient  simplicity  to  enable  the  clinician  to  judge  the 
functional  capacity  of  the  liver,  before  gross  organic 
lesions  or  indubitable  symptoms  have  appeared. 

Tests  for  liver  functional  capacity  may  be  profitably 
considered  under  five  headings.1  The  first  four  are 
endocrinous,  the  fifth  exocrinous.  They  are  as  follows : 
I.  Disturbance  of  the  glycogenic  function.  II.  Dis- 
turbance of  the  urcagenetic  function.  III.  Disturbance 
of  the  antitoxic  function.  IV.  Disturbance  of  the 
hemapoietic  function.  V.  Disturbance  of  the  biliary 
function. 

I.       FUNCTIONAL  TESTS  TO   DETERMINE   DISTURBANCES  OF 
THE    GLYCOGENIC    FUNCTION    OF    THE    LIVER 

Normally  the  liver  cells  retain  in  the  form  of  glycogcn 
almost  all  the  glucose  brought  to  them  from  the  ali- 

1  See  Les  Precedes  actuel  d'etude  de  1'insuffisance  hepatique. 
Gaz.  d.  hop.  Par.  1914,  no.  25,  p.  408  (Brule,  Garban).  To  this 
article  is  appended  an  extensive  bibliography. 


Tests  of  Liver  Function  15 

mentary  tract.  Under  certain  conditions  of  liver  in- 
sufficiency, glucose  is  not  fixed  by  the  cells,  and  passes 
immediately  into  the  blood,  producing  a  hyperglycemia, 
from  whence  it  is  excreted  in  the  urine.  This  fact  has 
been  utilized  as  a  basis  for  testing  the  glycogenetic 
integrity  of  the  liver  cell. 

The  name  of  Claude  Bernard  is  closely  linked  with 
the  history  of  the  physiology  of  hepatic  glycogenesis. 
Soon  after  the  discovery  by  Claude  Bernard  of  the  role 
of  the  liver  in  carbohydrate  metabolism,  the  use  of 
sugars  as  tests  for  hepatic  function  began. 

In  applying  the  sugar  test,  different  varieties  of 
sugars  have  been  employed,  particularly  saccharose 
(cane  sugar),  glucose,  levulose,  and  galactose.  The 
first  sugar  employed  for  this  purpose  was  saccharose 
(cane  sugar). 

The  sugar  tests  of  hepatic  function  are  four  in 
number,  as  follows:  1.  The  Cane  Sugar  test.  2.  The 
Glucose  test.  3.  The  Levulose  test.  4.  The  Galactose 
test. 

1.     The  Cane  Sugar  Test.    Colrat,  Lepme  Test 

150  to  200  grams  of  cane  sugar  syrup  are  adminis- 
tered to  the  subject  in  the  morning  while  fasting.  The 
urine  is  collected  every  hour  or  two  and  examined  for 
sugar  with  Fehling's  solution  or  other  means.  The 
presence  of  glycosuria  renders  the  test  positive. 

The  cane  sugar  test  was  considered  for  a  long  time 
the  best  criterion  of  liver  insufficiency.  The  clinical 
results  of  the  test  have,  however,  been  contradictory. 
A  rather  weighty  theoretical  objection  is  the  fact  that 
cane  sugar  must  be  converted  into  glucose  in  the  ali- 
mentary tract  before  it  can  be  utilized  by  the  organism, 
and  the  power  of  the  intestinal  juices  to  produce  this 


16     Manual  of  Vital  Function  Testing  Methods 

conversion  is  in  each  case  an  unknown  quantity  and 
therefore  a  source  of  error. 


#.     The  Glucose  Test 

The  patient  takes  in  the  morning  on  an  empty  stom- 
ach, 150  grams  of  pure  dextrin-free  glucose  dissolved 
in  300  c.  c.  of  water.  The  ingestion  of  this  amount 
should  not  take  over  a  quarter  of  an  hour. 

The  urine  is  then  collected  every  hour  or  two  for  ten 
hours  in  separate  vessels  and  tested  for  sugar,  the 
patient  remaining  on  a  milk  diet  during  the  time  re- 
quired by  the  test. 

Castaigne  has  advised  the  following  details  with  a 
view  of  perfecting  the  glucose  test.  For  several  days 
prior  to  the  performance  of  the  test,  the  subject  should 
be  kept  on  a  certain  known  quantity  of  carbohydrate. 
The  renal  permeability  should  be  investigated  and  the 
possibility  of  spontaneous  glycosuria  especially  after 
meals  eliminated. 

The  results  of  the  glucose  test  have  been  rather  con- 
flicting and  some  investigators  have  appeared  to  find 
glycosuria  following  the  test  in  apparently  healthy  sub- 
jects and  its  absence  in  certain  cases  of  hepatic  cirrhosis 
where  the  liver  parenchyma  would  have  been  acknowl- 
edged on  general  clinical  grounds  to  have  been  damaged. 

3.     The  Levulose  Test.     Strauss  Test 

This  test  was  introduced  by  Strauss  2  in  1901  as  a 
substitute  for  the  saccharose  and  glucose  tests. 

'  Berl.  klin.  Wchnschr.,  1898,  XXXV,  p.  398,  and  1899,  XXXVI, 
p.  1.59;  Deutsch.  med.  Wchnsch.,  1901,  XXVII,  p.  756,  also  1903, 
XXXIX,  p.  1T80. 


Tests  of  Liver  Function  17 

To  apply  the  test  100  grams  of  levulose  are  given  in 
the  morning  on  an  empty  stomach  and  the  urine  evacu- 
ated every  four  hours  thereafter  for  a  day  and  examined 
for  sugar  by  the  fermentation  test  or  polariscope. 

Owing  to  the  high  price  of  levulose,  honey,  which 
contains  a  large  percentage  of  it,  has  been  advised  as  a 
substitute. 

A  normal  person  should  tolerate  100  grams  of  levu- 
lose without  levulosuria. 

The  rationale  of  this  test  was  founded  on  the  experi- 
mental work  of  Sachs,3  who  found  that  frogs  whose 
livers  had  been  removed  had  a  lower  tolerance  for  levu- 
lose than  intact  controls.  With  dextrose  and  galactose 
this  was  not  the  case.  It  was  contended  therefore  that 
there  is  no  mechanism  besides  the  liver  capable  of 
handling  levulose,  while  there  is  such  an  extra  hepatic 
mechanism  in  the  case  of  glucose. 

Immediately  after  its  introduction,  this  test  came 
Into  pretty  general  use  and  was  commended  by  Ferra- 
nini  4  v.  Halasz,5  Bruining,6  and  others,  and  was  con- 
demned by  Landsberg,7  Churchman,8  and  others.  Much 
was  expected  from  the  levulose  test  because  as  above 
stated  it  was  believed  that  the  liver  alone  is  concerned 
in  levulose  metabolism.  However  this  may  be,  experi- 
ence has  apparently  failed  to  substantiate  the  hopes 
which  the  test  originally  inspired  and  it  is  not  now  be- 
lieved that  the  levulose  test  is  essentially  superior  to 
other  sugar  tests  of  hepatic  function. 

"Zeitschr.  f.  klin.  Med.,  1899,  XXXVIII.,  p.  87. 
*Zeitschr.   f.  inn.   Med.,  1902,  XXIII,  p.  921. 
8Wien.  klin.  Wchnschr.,  1908,  XXI,  p.  44. 
"Berl.  klin.  Wchnschr.,  1902,  XXXIX,  p.  587. 
'Deutsch.  med.   Wchnschr.,  1903,  XXIX,  p.  563. 
8  Johns  Hopk.  Hosp.   Bull.,  1912,  XXIII,  p.  10. 


18      Manual  of  Vital  Function  Testing  Methods 


4-     The  Galactose  Test.     Bauer's  Test 

Forty  grams  of  milk  sugar  dissolved  in  400-500  c.c. 
of  tea  are  taken  in  the  morning  on  an  empty  stomach. 
The  urine  is  passed  every  four  or  five  hours  thereafter 
and  examined  for  sugar. 

In  icterus  gravis  and  catarrhal  jaundice  this  test  has 
been  reported  as  giving  fairly  constant  results. 

Bauer 9  considered  the  galactose  test  especially 
adapted  to  determining  the  condition  of  liver  function  in 
catarrhal  jaundice.  The  amount  of  sugar  recovered 
in  the  urine  after  the  galactose  test  was  found  to  be 
greater  in  catarrhal  jaundice  than  in  obstructive  jaun- 
dice, consequently  it  was  supposed  that  the  test  would 
be  of  importance  in  differential  diagnosis  between  the 
two  conditions.  This  opinion  was  upheld  and  confirmed 
by  Bondi  and  Kb'nig,10  Riess  and  Jehn,11  and  Hi- 
rose.12 

Outside  of  catarrhal  jaundice  the  results  were  pro- 
nounced inconstant  by  Falk  and  Saxl,13  v.  Frey,14  and 
others. 

Conclusions  concerning  the  Sugar  Tests. — It  may  be 
said  that  the  investigation  of  hepatic  insufficiency  by 
any  or  all  of  the  sugar  tests,  is  to  be  regarded  merely  as 
supplementary  or  complementary  to  other  means  of 
investigation,  since  the  results  of  these  tests  alone  are 
not  conclusive.  Nevertheless  the  results  which  may  be 
obtained  by  their  help  when  associated  or  corelated  with 

"Wien.  med.  Wchnschr.,  1906,  LVI,  p.  2557. 
10Wien.  med.  Wchnschr.,  1910,  LX,  p.  2617. 
"Deutsch.    med.   Wchnschr.,    1912,    XXXVIII. 
12Deutsch.  Arch.  f.  klin.  Med.,  1912,  CVIII,  p.   187. 
13Ztsch.  f.  klin.  Med.,  1911,  LXXIII,  p.   131,  325. 
"Ztschr.  f.  klin.  Med.,  1911,  LXXII,  p.  383. 


Tests  of  Liver  Function  19 

those  obtained  by  other  methods  are  of  sufficient  value 
to  justify  their  retention  in  clinical  medicine. 

It  is  now  understood  that  the  mechanism  whereby 
alimentary  glycosuria  is  produced  is  more  complex  than 
was  formerly  supposed,  and  that  the  liver  is  not  the 
only  organ  involved  in  the  process.  Other  tissues  are 
now  known  to  be  concerned  in  glycofixation  and  mobil- 
ization. Furthermore,  the  individual  coefficient  of  sugar 
utilization  has  been  found  to  vary  within  quite  wide 
limits,  50-350  grams  of  levulose  for  example.  The  co- 
efficient varies  also  in  the  same  individual  for  the  dif- 
ferent sugars  so  that  in  reporting  results  of  sugar  tests 
it  is  deemed  expedient  to  specify  the  particular  kind  of 
sugar  used. 

The  unknown  factors  of  intestinal  absorption  and 
renal  permeability  complicate  all  sugar  tests. 

The  sugar  tests  have  been  found  positive,  especially 
in  severe  bivenous  cirrhosis,  in  icterus  gravis  and  in 
cholelithiasis.  They  are,  however,  of  no  prognostic 
value. 

A  recent  comprehensive  study  of  the  applicability  of 
carbohydrates  as  tests  for  hepatic  functional  activity 
has  been  made  by  Bloomfield  and  Horwitz.15  These 
authors  call  attention  very  properly  to  the  factors 
which  tend  to  render  the  sugar  tests  for  hepatic  func- 
tion unreliable.  The  great  theoretical  stumbling  block 
in  the  way  of  accepting  the  finding  of  the  carbohydrate 
tests  is  the  fact  that  extra-hepatic  factors  of  consider- 
able importance  are  concerned  in  the  sugar  regulating 
metabolism.  Some  of  the  glands  of  internal  secretion 
take  part  in  this.  Certain  lesions  of  the  hypophysis 
may  cause  glycogenolysis  and  glycosuria,  while  with 
other  hypophyseal  lesions  the  sugar  tolerance  is  in- 

15  Johns  Hopk.  Hosp.  Bull.,  1913,  XXIV,  p.  375:— a  good  bibli- 
ography is  appended  to  this  article. 


20      Manual  of  Vital  Function  Testing  Methods 

creased. 

The  internal  secretion  of  the  pancreas  is  generally 
considered  to  exert  an  inhibitory  effect  on  the  mobiliza- 
tion of  glycogen  by  the  liver.  The  suprarenals  have  an 
accelerating  effect  on  the  same  mechanism.  The  thy- 
roid gland  also  takes  part  in  sugar  metabolism,  the 
exact  nature  of  which  is  unknown.  Both  the  autonomic 
and  sympathetic  nerves  likewise  affect  the  mobilization 
of  glycogen.  These  last  facts,  of  course,  tend  to  render 
the  sugar  tests  less  definite  and  satisfactory. 

From  a  practical  standpoint  it  cannot  be  denied  that 
the  sugar  tests  have  certain  disadvantages.  It  is  diffi- 
cult for  patients  to  ingest  the  large  quantities  of  sugars 
required  without  the  occurrence  in  certain  cases  of 
nausea,  vomiting  and  diarrhoea.  Faulty  absorption, 
intestinal  fermentation,  portal  obstruction  with  col- 
lateral circulation,  sugar  retention  due  to  nephritis, 
inconstancies  in  the  diet  also  combine  to  render  the 
results  inaccurate. 

It  will  remain  for  the  future,  however,  to  determine 
whether  the  sugar  tests  of  hepatic  insufficiency  can  be 
developed  or  modified  in  such  a  way  that  the  rather 
numerous  objections  with  which  impartial  observers  are 
agreed  the  tests  are  encumbered,  may  be  eliminated. 
In  such  an  event  these  tests,  which  from  an  historical 
standpoint  are  so  interesting,  may  take  a  definite  place, 
even  though  subsidiary,  in  that  important  group  of 
tests  by  which  one  seeks  to  obtain  an  insight  into  the 
functional  integrity  of  the  liver. 

II.        FUNCTIONAL  TESTS  TO  DETERMINE  DISTURBANCES  OF 
THE   UREAGENETIC    FUNCTION    OF    THE    LIVER 

All  the  tests  for  hepatic  function  which  deal  with 
the  ureagenctic  activity  of  the  liver  are  concerned  with 


Tests  of  Liver  Function  21 

the  question  of  nitrogen  metabolism.  The  liver  plays  a 
large  and  important  part  in  this  metabolism;  perhaps 
not  so  exclusive  a  role,  however,  as  was  formerly  sup- 
posed. 

The  ureagenetic  function  tests  are,  for  the  most  part, 
merely  studies  of  nitrogen  metabolism.  They  consist 
mostly  of  estimations  of  the  amount  of  nitrogen  elimi- 
nated in  the  urine  with  accurate  partition  of  this  nitro- 
gen into  different  groups,  particularly  urea  and  am- 
monia. The  relation  between  the  amount  of  nitrogen 
eliminated  in  these  two  forms  when  compared  with  the 
total  nitrogen  eliminated  will  afford  valuable  criteria 
for  estimating  the  ureagenetic  functional  capacity  of 
the  liver. 

The  practical  estimation  of  ureagenetic  functional 
capacity  of  the  liver  involves  much  more  complex  series 
of  chemical  processes  than  were  found  to  be  involved  in 
the  investigation  of  the  carbohydrate  function  by  means 
of  the  sugar  tests.  Inasmuch  as  the  first  criterion  of 
normal  liver  function  from  the  standpoint  of  nitrogen 
metabolism  involves  the  relation  between  the  amount  of 
urea  excreted  in  the  urine  and  the  amount  of  total 
nitrogen  excreted  therein,  the  investigator  must  make 
two  separate  chemical  analyses.  First  the  exact  amount 
of  urea  excreted  must  be  estimated,  and  second,  the 
exact  amount  of  total  nitrogen  eliminated.  In  discuss- 
ing these  analyses,  no  attempt  will  be  made  to  give  any 
data  beyond  the  description  of  such  methods  which,  on 
account  of  their  comparative  simplicity  and  established 
accuracy,  have  become  firmly  established  in  the  clinic. 
The  estimation  of  total  nitrogen  in  the  urine  by  the 
standard  method — that  of  Kjeldahl — requires  a  good 
deal  of  time  and  some  technical  skill.  But  it  is  a  method 
which  can  be  easily  performed  in  any  well-equipped 
laboratory  attached  to  a  hospital,  and  should  be  car- 


22      Manual  of  Vital  Function  Testing  Methods 

ried  out  by  a  competent  person.  A  rapid  and  accurate 
method  of  quantitative  estimation  of  urea  has  been 
lately  devised — that  of  Marshall — and  this  method  has 
already  become  the  standard  one  in  the  clinic. 

The  estimation  of  urinary  ammonia,  or  ammonia 
nitrogen,  is  another  step  required  in  the  study  of  the 
efficiency  of  the  liver  from  the  standpoint  of  nitrogen 
metabolism.  Here  also  it  is  best  for  the  clinician  to 
familiarize  himself  with  one  method,  preferably  that  of 
Folin,  the  details  of  which  are  further  on  discussed. 

The  actual  administration  of  ammonium-bearing  or 
amino-acid-containing  substances  to  the  patient,  with 
the  subsequent  examination  of  the  urine  to  determine 
the  capacity  of  the  liver  to  convert  these  substances  into 
urea,  is  another  method  of  clinical  investigation  of  the 
liver  function.  Finally  it  is  conceded  that  the  estima- 
tion of  rest  or  residual  nitrogen  in  the  blood  serum  may 
be  utilized  to  determine  whether  or  not  the  liver  cell  is 
capable  of  producing  an  adequate  urea  synthesis  of 
nitrogen  products  in  the  body. 

To  recapitulate,  we  may  tabulate  the  different  meth- 
ods of  testing  the  ureagenetic  functional  power  of  the 
liver  under  the  following  heads  and  in  this  order  they 
will  be  discussed:  1.  Urea  Elimination  and  Nitrogen 
Coefficient  as  Criteria  of  Ureagenetic  Liver  Function ; 
2.  Augmentation  of  Urinary  Ammonia  as  an  Index  of 
Ureagenetic  Liver  Function ;  3.  Amino-aciduria  as  a 
Criterion  of  Ureagenetic  Liver  Function ;  4.  Estima- 
tion of  Residual  Nitrogen  in  the  Blood  Serum  as  an 
Index  of  Ureagenetic  Liver  Function. 

1.     Urea  Elimination  and  Nitrogen  Coefficient  as 
Criteria  of  Liver  Function 

Urea  Elimination,- — The  liver  has  long  been  regarded 
as  the  chief  source  of  urea,  which  substance  is  supposed 


Tests  of  Liver  Function  23 

to  be  formed  from  ammonium  salts,  amino  acids  and 
products  of  nitrogenous  catabolism. 

The  urea  synthesis  is  supposed  to  be  the  work  of  the 
liver  cell  governed  by  ferments  which  it  secretes. 

It  has  long  been  recognized  that  in  certain  diseases  of 
the  liver  the  percentage  of  urea  eliminated  in  the  urine 
is  lowered.  Therefore  diminution  of  urea  excretion 
may  sometimes  indicate  hepatic  insufficiency  and  an 
estimation  of  the  quantity  of  urea  eliminated  is  there- 
fore an  available  factor  in  testing  the  ureagenetic  func- 
tion of  the  liver  cell. 

The  quantity  of  urea  eliminated  in  the  urine  by  a 
healthy  adult  in  24  hours  is  25  to  30  grams.  In  cases 
of  hepatic  insufficiency  this  quantity  may  fall  to  10,  5, 
3  or  .5  grams  or  even  0  in  icterus  gravis. 

But  before  one  can  attribute  a  diminution  of  urea 
elimination  to  functional  disorder  of  the  liver,  certain 
other  factors  of  great  importance  must  be  taken  into 
consideration.  One  of  these  is  the  functional  capacity 
of  the  kidney.  It  is  well  understood  that  urea  retention 
in  the  blood  may  be  due  to  defect  of  kidney  permeability. 

Another  important  factor  is  the  amount  of  proteid 
intake.  Before  attempting  to  draw  any  conclusions 
with  respect  to  the  relation  of  urea  elimination  to  the 
ureagenetic  functional  capacity  of  the  liver  it  will  al- 
ways be  necessary  that  the  individual  to  be  tested  shall 
be  placed  for  a  sufficient  length  of  time  upon  a  fixed 
ration  in  which  the  amount  of  proteid  is  known  and 
invariable. 

The  Nitrogen  Coefficient. — The  relation  of  urea  ni- 
trogen to  the  total  nitrogen  excreted  in  the  urine  is 
known  as  the  coefficient  of  nitrogen  elimination.  This 
coefficient  may  be  important  since  under  certain  circum- 
stances its  diminution  may  constitute  a  valuable  sign 
of  ureagenetic  hepatic  insufficiency. 


24      Manual  of  Vital  Function  Testing  Methods 

The  nitrogen  coefficient  is  usually  expressed  by  the 
following  fraction: 

N.    urea 


N.  total 

the  arithmetical  relation  in  other  words  between  the 
amount  of  nitrogen  eliminated  in  the  urine  as  urea  and 
the  total  quantity  of  nitrogen  eliminated.  This  co- 
efficient will  diminish  in  proportion  to  the  diminution 
of  urea  nitrogen. 

According  to  some  authors  a  diminution  of  the  ni- 
trogen coefficient  is  absolutely  constant  in  hepatic  in- 
sufficiency. 

The  normal  figures  of  the  nitrogen  coefficient  vary 
from  85%  to  95%.  In  icterus  gravis  it  has  been  found 
reduced  to  40 ;  likewise  in  phosphorus  poisoning. 

But  just  as  in  estimating  the  percentage  of  urea  in 
the  urine  and  considering  the  same  as  an  index  of  he- 
patic function,  so  also  in  determining  the  coefficient  of 
nitrogen  elimination  for  the  same  purpose  the  patient 
must  be  placed  on  a  fixed  and  invariable  proteid  regi- 
men, though  the  absolute  quantity  of  proteid  taken  is 
negligible. 

It  must  also  be  previously  known  that  there  is  no 
deficiency  in  renal  permeability.  To  determine  the  co- 
efficient of  nitrogen  elimination,  two  operations  must  be 
performed.  First,  a  quantitative  estimation  of  urea 
must  be  made,  from  which  the  calculation  of  urea  nitro- 
gen may  readily  be  accomplished.  Secondly,  the  total 
nitrogen  eliminated  in  the  urine  must  be  estimated  and 
this  part  of  the  operation  is,  unfortunately,  somewhat 
difficult  and  time-consuming.  The  simplest  known 
means  for  performing  these  operations  will  be  given. 

Quantitative  Estimation  of  Urea  in  Urine. — Several 


Tests  of  Liver  Function  25 

methods  are  in  use  for  determining  quantitatively  the 
amount  of  urea  in  urine.  One  of  the  most  frequently 
used  is  the  hypobromite  method,  using  the  ureometer  of 
Doremus.  In  this  method  nitrogen  is  set  free  by  sodium 
hypobromite  and  measured  in  the  apparatus.  The  re- 
sults obtained  by  this  method  are  extremely  inaccurate 
and  it  is  not  used,  therefore,  where  absolute  results  are 
required. 

Three  other  methods  which  are  much  more  depend- 
able have  been  in  use  for  some  years  in  the  laboratories. 
These  are:  1.  The  Morner-Sjoqvist;16  2.  Folin's 
method  ;17  and  3.  Schondorff's  method.18  The  details  of 
these  methods  may  be  found  in  any  modern  text  book 
on  laboratory  methods.  We  shall  not  give  a  descrip- 
tion of  them  here. 

Marshall's  Method  of  Urea  Estimation. — Quite  re- 
cently a  rapid  chemical  method  for  the  estimation  of 
urea  in  urine  has  been  introduced  by  Marshall  of  Johns 
Hopkins.19  It  depends  upon  the  conversion  of  urea  into 
ammonium  carbonate  by  means  of  an  enzyme  prepared 
from  soy  bean.  This  enzyme  is  called  urease  because  of 
its  facility  in  effecting  this  conversion.  Urease  is  found 
in  some  bacteria  and  fungi.  The  following  formula 
represents  the  chemical  decomposition  produced: 

NH2  ONH4 

CO         +2H2O  =  CO 
NH2  ONH4 

The  presence  of  urease  in  soy  bean  (glycine  hispida) 
was  first  observed  by  Takeuchi  in  Japan.  Its  applica- 

16Skand.  Arch.  f.  Phys.,  1891,  II,  p.  438;  Zeit.  f.  phys.  Chem., 
XVII,  p.  140. 

"Zeit.  f.  phys.  Chem.,  1901,  XXXII,  p.  504. 
"Arch.  f.  d.  Ges.  Phys.,  1896,  LXII,  p.  1. 
19  Jour,  of  Biol.  Chem.,  1913,  XIV,  no.  3;  1913,  XV,  no.  3. 


26      Manual  of  Vital  Function  Testing  Methods 

tion  to  the  quantitative  estimation  of  urea  is  due  as 
above  stated  to  Marshall. 

A  convenient  form  of  the  enzyme  urease  is  now  to 
be  found  upon  the  market  under  the  name  of  urease 
(Dunning).  It  is  supplied  in  convenient  25  milligram 
tablets  put  up  40  tablets  per  package  by  Hynson  West- 
cott  &  Co.,  pharmaceutical  chemists  of  Baltimore, 
Maryland. 

Urease  (Dunning)  is  a  fine,  almost  white,  powder, 
with  little  taste  or  odor,  soluble  in  slightly  alkaline 
water. 

The  apparatus  and  material  required  for  the  estima- 
tion are  as  follows :  Four  200  c.c.  Erlenmeyer  flasks 
with  cork  stoppers ;  one  50  c.c.  glass-stoppered  burette ; 
one  5  c.c.  bulb  pipette;  one  small  glass  mortar;  100  c.c. 
of  solution  of  methyl  orange;  1000  c.c.  of  decinormal 
solution  of  HC1;  50  c.c.  toluol  and  a  package  of  urease 
(Dunning)  tablets. 

Put  1  or  2  c.c.  of  toluol  into  each  of  two  Erlenmeyer 
flasks  of  200  c.c.  capacity.  Into  one  of  the  flasks  intro- 
duce exactly  5  c.c.  of  a  specimen  of  urine  and  100  c.c. 
of  distilled  water;  stopper  flask  with  cork.  Crush  a 
urease  tablet  in  a  small  glass  mortar  and  dissolve  in 
about  5  c.c.  of  water.  Transfer  this  solution  without 
loss  into  the  other  flask  containing  toluol  and  rinse 
mortar  with  several  portions  of  distilled  water  until 
about  100  c.c.  have  been  added  to  the  contents  of  the 
second  flask.  Add  5  c.c.  of  the  urine  and  stopper  with 
a  cork. 

Each  flask  is  now  thoroughly  shaken  and  allowed  to 
stand  at  room  temperature  over  night  or  at  least  8 
hours.  If  it  is  necessary  to  get  more  rapid  estimations 
two  tablets  are  used  instead  of  one  and  the  mixture 
digested  at  40  °C  for  an  hour. 

The  test  may  indeed  be  completed  in  15  minutes  by 


Tests  of  Liver  Function  27 

using  only  1  c.c.  of  urine,  two  tablets  and  digesting  at 
40°  Centigrade  for  15  minutes.  The  factor  would  in 
this  case  be  3  instead  of  .6,  as  will  be  seen  later  by 
carrying  out  the  longer  time  limit. 

After  the  lapse  of  the  time  set  the  two  solutions  are 
titrated  to  a  distinct  pink  color  with  decinormal  HC1, 
using  methyl  orange  as  indicator. 

The  urease  has  converted  the  urea  present  in  the  urine 
into  ammonium  carbonate.  The  amount  of  ammonium 
carbonate  formed  by  the  urease  is  indicated  by  the 
quantity  of  standard  HC1  solution  required  to  exactly 
neutralize  the  contents  of  the  flask  containing  urease 
minus  the  quantity  required  for  control  specimen. 

According  to  the  chemical  formula  representing  the 
conversion  of  urea  into  ammonium  carbonate  (z?.  s.)  it 
may  be  seen  that  60  grams  of  urea  are  converted  (by 
urease)  into  96  grams  of  ammonium  carbonate.  This 
amount  (96  grams)  of  ammonium  carbonate  would 
require  72  grams  of  standard  HC1  solution  to  neu- 
tralize it. 

As  this  quantity  of  HC1  solution  (72  grams)  is  con- 
tained in  20,000  c.c.  of  n/10  HC1  solution  and  is 
equivalent  to  60  grams  of  urea  represented  by  96  grams 
of  ammonium  carbonate,  then  1/20000  of  the  quantity 
of  1  c.c.  of  n/10  HC1  solution  will  be  equivalent  of 
1/20000  of  60  grams,  equal  .003  (60-^20000 =.003). 

Therefore  each  c.c.  of  decinormal  HC1  solution  re- 
quired to  neutralize  the  enzyme  treated  specimen  minus 
the  number  of  c.c.  required  to  neutralize  the  control 
specimen  represents  .003  of  urea,  and  as  the  5  c.c.  speci- 
men is  the  1/ooo  Part  of  a  liter,  multiply  the  number  of 
c.c.  of  n/io  HC1  solution  in  excess  of  the  control  re- 
quirements by  the  factor  .6  (.003X200=.6)  to  find  the 
urea  per  liter  when  estimating  the  daily  output. 

One  part  of  nitrogen  is  equivalent  to  2.143  parts  of 


28      Manual  of  Vital  Function  Testing  Methods 

urea. 

Estimation  of  Total  Nitrogen  in  the  Urine.  Kjel- 
dahl's  Method.20 — Ten  c.c.  of  urine  are  carefully  meas- 
ured into  a  Jena  glass,  round-bottom  flask.  Add  a  few 
drops  of  concentrated  solution  of  sulphate  of  copper, 
15  c.c.  of  H2SO4  and  10  grams  of  potassium  sulphate. 

The  flask  is  supported  in  an  inclined  position  to  pre- 
vent loss  by  spurting.  The  mouth  of  the  flask  is  loosely 
closed  by  a  glass  bulb  blown  on  end  of  a  piece  of  glass 
tubing. 

The  flask  may  be  conveniently  supported  by  a  thick 
piece  of  asbestos  board  with  a  hole  in  the  center  of  a 
size  to  permit  the  flame  to  come  in  contact  only  with  the 
portion  of  flask  covered  by  fluid.  Wire  gauze  protects 
the  flask  from  direct  contact  with  the  flame. 

The  flask  should  now  be  gently  heated  over  a  Bunsen 
flame  for  half  an  hour.  When  foaming  ceases  the  flame 
is  raised  until  the  acid  begins  to  boil  gently.  The  whole 
heating  process  is  carried  out  under  a  hood  because  of 
sulphurous  acid  fumes  which  are  given  off.  When  the 
fluid  in  the  flask  is  colorless  or  pale  green,  oxidation  is 
complete.  This  requires  about  two  hours.  The  acid 
and  the  oxidizer  (CuS04)  convert  all  nitrogenous  mat- 
ter into  ammonium  sulphate.  The  flask  is  then  cooled. 
The  next  step  is  distillation.  The  same  or  a  larger 
Jena  glass  flask  may  be  used,  but  preferably  a  copper 
apparatus  which  will  not  break.  Two  hundred  c.c.  of 
water  are  added  and  enough  30%  NaOH  solution  to 
make  the  mixture  strongly  alkaline.  Ammonia  is  set 
free  by  the  action  of  the  alkali.  This  is  distilled  over 
in  80  c.c.  of  decinormal  H2SO4,  which  has  been  accu- 
rately measured  into  a  flask.  The  flask  containing  the 
original  solution  is  heated  until  about  2/3  of  it  have 
passed  over  and  there  is  considerable  bumping  from 
80  Zeit.  f.  Chem.,  1883,  XXII,  p.  3T8. 


Tests  of  Liver  Function  29 

the  separation  of  sodium  sulphate.  This  usually  re- 
quires about  thirty  minutes.  Bumping  may  be  dimin- 
ished by  adding  fragments  of  pumice,  granulated  zinc 
or  talcum  powder  at  the  beginning  of  distillation.  A 
simple  form  of  apparatus  can  be  extemporized  in  the 
laboratory.  [See  Illustration.] 


The  tube  D  contains  a  few  glass  beads  and  some  of 
the  H2SO4  is  poured  over  these  to  prevent  the  escape  of 
any  ammonia.  A  few  drops  of  methyl  orange  are 
added  to  the  pearls  and  the  flask  C  to  indicate  alkalin- 
ity, in  which  event  more  acid  is  to  be  added  promptly. 
D  is  not  necessary  if  a  Liebig  condenser  is  used. 

The  tube  B  prevents  the  alkaline  fluid  in  A  from 
spurting  over  into  E.  The  tubes  E  and  B  are  made  of 
broken  pipettes  of  50  or  100  c.c.  capacity. 

The  decinormal  acid  into  which  the   ammonia  has 


30      Manual  of  Vital  Function  Testing  Methods 

condensed  is  titrated  with  n/10  NaOH.  Methyl  orange 
is  used  as  an  indicator. 

Subtract  the  number  of  c.c.  of  decinormal  NaOH 
used  from  the  number  of  c.c.  of  acid  taken  and  the 
remainder  will  give  the  amount  of  ammonia  distilled 
over,  for  every  c.c.  of  acid  neutralized  by  the  ammonia 
is  equivalent  to  so  much  decinormal  ammonia. 

Decinormal  ammonia  contains  1.4  grams  of  nitrogen 
to  the  liter  or  .0014  gram  per  one  c.c.  The  amount 
of  nitrogen  can  therefore  be  determined  by  multiplying 
the  number  of  c.c.  of  acid  neutralized  by  .0014.  This 
gives  the  nitrogen  in  grams  for  10  c.c.  of  urine  used. 

The  description  of  the  method  given  above  is  taken 
from  Wood's  Chemical  Diagnosis,  N.  Y.,  1909,  p.  408. 

2.     Augmentation  of  Urinary  Ammonia  as  an  Index  of 
Ureagenetic  Liver  Function 

Ammonia,  amino  acids  and  carbonates  constitute  the 
last  intermediaries  in  the  metabolic  processes  by  which 
the  body  proteids  are  catabolized  into  urea.  As  before 
stated,  the  liver  has  been  regarded  as  the  chief  factor  in 
this  conversion. 

If  the  functional  capacity  of  the  liver  is  deficient, 
the  amount  of  nitrogen  eliminated  in  the  form  of  am- 
monia will  be  increased.  Normally,  .7  gram  of  am- 
monia are  excreted  by  the  urine  in  24  hours.  In  hepatic 
insufficiency  the  amount  may  be  doubled  or  trebled. 

The  relation  of  ammonia  nitrogen  to  total  nitrogen 
in  the  urine  is  normally  3  or  4  parts  per  hundred. 
Under  pathological  conditions,  however,  it  may  rise  to 
30  parts  per  100  and  such  an  increase  may,  under  cer- 
tain circumstances,  indicate  hepatic  insufficiency.  In 
states  of  acidosis  the  ammonia  nitrogen  is  also  increased. 


Tests  of  Liver  Function  31 

It  is  often  useful  to  make  a  comparison  between  the 
amount  of  nitrogen  excreted  as  ammonia  and  the  nitro- 
gen eliminated  as  urea.  This  is  done  as  follows :  The 
molecular  weight  of  ammonia  NH3  is  17,  the  nitrogen 
fraction  of  ammonia  is,  therefore,  14/i7- 

NH2 

The  molecular  weight  of  urea  CO         is  60. 

NH2 

The  nitrogen  fraction  is  28/6o  or  7/i5. 

The  amount  of  ammonia  in  grams  in  a  given  sample 
is  estimated  by  the  formalin  method  (v.  «.),  and  14/i7 
of  this  represents  the  ammonia  nitrogen.  The  urea  is 
calculated  in  grams  in  the  same  sample  of  urine,  by 
Marshall's  method,  and  T/15  of  the  weight  is  nitrogen. 
Under  normal  conditions  the  ammonia  nitrogen  is  about 
1/20  of  the  urea  nitrogen. 

Estimation  of  Ammonia  Nitrogen  in  the  Urine.  The 
Formalin  Method. — The  estimation  of  acidity  is  the 
first  stage  in  the  estimation  of  ammonia  nitrogen.  Pro- 
ceed as  follows : 

Measure  out  25  c.c.  of  urine  into  a  beaker  and  dilute 
with  about  double  the  volume  of  distilled  water.  Add 
2  or  3  drops  of  phenolphthalein.  Run  in  n/10  NaOH 
from  a  burette  until  a  faint  permanent  pink  color  is 
produced.  Note  the  number  of  c.c.  of  NaOH  used. 
Measure  about  10  c.c.  of  commercial  (40%)  formalin 
into  a  second  beaker.  Add  phenolphthalein.  Neutral- 
ize exactly  with  n/10  NaOH.  Add  the  neutral  formalin 
to  the  neutral  urine.  The  pink  color  disappears.  Run 
in  n/10  NaOH  until  the  pink  color  returns.  Note  the 
number  of  c.c.  of  NaOH  used.  The  result  is  calculated 
in  terms  of  n/10  NaOH  for  the  acidity.  That  is  to  say 
the  acidity  of  the  urine  is  given  as  the  number  of  c.c.  of 
n/io  NaOH  required  to  neutralize  100  c.c.  of  urine  to 
phenolphthalein.  Thus  if  10  c.c.  of  soda  were  used  in 


32      Manual  of  Vital  Function  Testing  Methods 

the  first  titration  to  neutralize  25  c.c.  of  urine,  the  acid- 
ity of  the  urine  is  10/25X1QO:=40.  The  ammonia  re- 
sult should  be  expressed  in  grams  of  ammonia  per  24 
hours.  The  number  of  c.c.  of  soda  used  in  the  second 
titration  of  the  urine  is  the  equivalent  of  the  number  of 
c.c.  of  ammonia  present  in  the  25  c.c.  of  urine.  Sup- 
posing the  number  of  c.c.  of  soda  used  in  the  second 
titration  to  have  been  10,  then  10  c.c.  n/10  NaOH= 
10  c.c.  n/10  NH3  =  10  X  -0017  gm.  NH3.  Therefore  the 
ammonia  passed  in  the  24  hours  =  10  X  .0017  X 
24  hours  urine  in  c.c. 


25 

The  reaction  depends  upon  the  combination  of  the  am- 
monium salts  with  formaldehyde  to  form  urotropinc 
and  the  consequent  liberation  of  the  acids  previously 
combined  with  ammonia. 

Experimental  Provocative  Ammoniuria. — This  test 
is  based  upon  the  fact  that  normally,  the  liver  trans- 
forms all  ammonia  transported  to  it  into  urea.  If  there 
is  pathological  alteration  of  the  liver  cell,  this  am- 
monia will  not  be  transformed  and  the  quantity  of 
ammonia  in  the  urine  increases. 

Before  applying  the  test  of  provocative  ammoniuria 
in  a  given  case  the  total  ammonia  excretion  in  24  hours 
should  be  estimated  over  two  days.  Meanwhile  the 
patient  is  put  upon  a  fixed  regimen. 

In  the  morning,  after  having  urinated,  the  subject  is 
given  6  grams  of  ammonium  acetate.  The  urine  for  the 
next  24  hours  is  collected  and  the  ammonium  content 
estimated  (v.  s.)  which  can  be  compared  with  that 
found  prior  to  the  test. 

The  value  of  this  test  is  variously  estimated.  Some 
have  concluded  that  any  considerable  increase  of  am- 
monia in  the  urine  after  the  ingcstion  will  always  in- 


Tests  of  Liver  Function  33 

dicate  an  impairment  of  the  functional  integrity  of  the 
liver  cell.  It  is  only  claimed  to  be  of  value  when  posi- 
tive. Others,  on  the  contrary,  have  insisted  that  in  spite 
of  very  advanced  disease  of  the  liver  the  ammonium 
salts  ingested  continue  to  be  transformed  into  urea. 

3.     Aminoaciduria  as  a  Criterion  of  Ureagenetic 
Function 

The  existence  of  considerable  quantities  of  amino 
acids,  leucine  and  tyrosine,  in  the  urine  in  liver  diseases 
was  noted  in  1866  by  Frerichs.  In  1907  Glaessner  21 
showed  that  in  disease  of  the  liver  there  is  usually  an 
increase  in  the  relation  of  amino  nitrogen  to  total  nitro- 
gen in  the  urine.  Normally  this  relation,  or  so  called 
coefficient,  of  aminoaciduria  has  been  shown  to  vary 
from  .5  to  3.5  per  100.  In  diseases  of  the  liver  (chole- 
lithiasis, cirrhosis),  the  ratio  may  rise  to  11  or  even  13 
per  100. 

Labbe  and  Bith  have  estimated  the  amount  of  amino 
acids  in  the  blood  serum  and  have  found  it  increased  in 
certain  liver  diseases. 

Hyperaminoaciduria,  according  to  Brille  and  Gar- 
ban,22  is  not  necessarily  an  indication  of  liver  disease. 
It  may  occur  during  states  of  rapid  emaciation,  cach- 
exia,  pneumonia,  typhoid  fever  and  diabetes  compli- 
cated with  acidosis. 

These  authors  agree,  however,  that  in  all  these  states 
it  may  not  be  improbable  that  the  appearance  of  am- 
inoaciduria is  dependent  upon  a  disturbance  of  the 
function  of  the  liver  cell. 

Provocative  Aminoaciduria. — The  principal  sub- 
stances which  have  been  used  are  glycocol,  alanin,  as- 

aZeit.  f.  Exper.  Path.  Therap.,  1907,  IV,  p.  336. 
22  Gaz.  d.  Hop.,  1914,  LXXXVII,  p.  405. 


34      Manual  of  Vital  Function  Testing  Methods 

paraginic  acid,  and  commercial  peptone.  These  amino 
acids,  also  peptone,  have  been  employed  by  different 
experimenters.23  The  patient  is  given  certain  quanti- 
ties of  these  substances  and  the  amount  of  amino-acid 
excreted  in  the  urine  carefully  measured. 

If  the  proper  care  has  been  taken  in  the  days  which 
precede  the  test  to  establish  the  normal  amino  nitrogen 
coefficient  for  the  individual  and  to  keep  the  subject 
under  observation  upon  a  fixed  and  invariable  diet,  then 
provocative  aminoaciduria  tests  may  be  of  value.  They 
will  frequently  show  a  marked  increase  of  the  coefficient 
after  the  ingestion  of  the  amino-acids  (or  peptones) 
as  compared  with  the  coefficient  prior  to  the  test,  and 
the  marked  increase  according  to  some  authors  will 
only  occur  when  the  liver  parenchyma  is  diseased. 

The  insuperable  difficulty  in  these  methods  of  esti- 
mating liver  function  arises  from  the  fact  that  the  esti- 
mation of  amino  nitrogen  in  urine  and  blood  requires 
very  complicated  chemical  manipulations  which  effectu- 
ally prevent  their  introduction  into  clinical  medicine. 

4-     Estimation  of  Residual  Nitrogen  in  Blood  Serum 
as  an  Index  of  Hepatic  Function.    Chauffard  Brodin 

Test  24 

The  quantity  of  residual  nitrogen  in  blood  serum  is 
obtained  by  subtracting  the  urea  nitrogen  from  the 
total  nitrogen  estimated  in  dealbuminized  serum.  Re- 
sidual nitrogen  is  made  up  of  ammonia,  amino-acid, 
uric  acid,  etc.  It  has  been  contended  that  the  elabora- 
tion of  residual  nitrogen  products  is  exclusively  de- 

""Ztschr.  f.  klin.  Med.,  1910,  LXXI,  p.  261;  1911,  LXXIII,  p. 
325. 

24  Jour.  Biol.  Chem.,  1912,  XII,  p.  301;  Jour.  Amer.  Chem.  Soc., 
1913,  XXV,  p.  1567, 


Tests  of  Liver  Function  35 

pendent  upon  the  liver.  In  normal  persons  the  re- 
sidual nitrogen  is  always  below  10  grams  per  liter 
of  serum.  In  many  acute  and  chronic  diseases  of 
the  liver,  the  residual  nitrogen  has  been  found  above 
10  grams,  the  amount  being  in  proportion  to  the  grav- 
ity of  the  hepatic  lesion.  The  diet  and  condition  of 
the  kidney  are  negligible. 

The  estimation  of  the  amount  of  residual  or  rest 
nitrogen  in  the  blood  serum  has  come  to  be  regarded 
as  of  more  importance  as  a  test  of  kidney  than  of  liver 
function.  For  this  reason  a  more  complete  account  of 
the  method  and  its  interpretation  will  be  found  later 
under  that  head. 

General  Summary  of  the  Value  of  Ureagenetic  Func- 
tion Tests. — In  the  first  place  it  must  be  admitted  that 
some  of  these  ureagenetic  tests  are  complicated  to  such 
an  extent  that  they  cannot  be  carried  out  without  the 
assistance  of  an  expert  chemist,  thus  diminishing  their 
applicability  to  clinical  work. 

Further  than  this  it  must  likewise  be  admitted  that 
many  physiological  causes  of  error  exist  which  militate 
against  a  too  strict  interpretation  of  results.  Other 
factors  besides  the  liver  collaborate  in  nitrogen  metab- 
olism. 

Notwithstanding  these  valid  objections  it  must  be 
admitted  that  the  study  of  nitrogen  has  given  some 
useful  results  and  it  is  to  be  hoped  that  future  investi- 
gations may  bring  a  greater  degree  of  order  from  the 
now  more  or  less  confused  and  contradictory  material 
which  comprises  our  stock  of  knowledge  today  concern- 
ing the  true  relation  of  the  liver  to  nitrogenous  metab- 
olism. 

When  this  day  arrives  the  clinician  will  be  better 
able  to  interpret  the  results  obtained  from  ureagenetic 
tests  than  he  is  at  the  present  time. 


36      Manual  of  Vital  Function  Testing  Methods 

in.       FUNCTIONAL     TESTS     TO     DETERMINE     DISTURBANCE 
OF    THE    ANTITOXIC    FUNCTION    OF    THE    LIVER 

Poisons  which  obtain  access  to  the  organism  thro 
the  portal  circulation  are  fixed  and  destroyed  under 
normal  circumstances  by  the  liver  cells.  It  is  natural, 
therefore,  that  this  important  function  should  be  em- 
ployed as  a  basis  for  testing  the  integrity  of  the  organ. 

The  first  efforts  made  in  this  direction  consisted 
in  estimating  the  toxicity  of  urine  and  blood  serum. 
An  increase  of  toxicity  of  these  bodies,  it  was  held,  in- 
dicates diminished  toxicopexic  power  of  the  liver  paren- 
chyma. Tests  of  this  character  are  carried  out  upon 
lower  animals.  The  urine  to  be  tested  being  injected 
intravenously  into  rabbits  according  to  Bouchard's  25 
method,  and  blood  serum  or  urine  into  the  cerebrum 
of  rabbits  according  to  Widal's  method.  The  numerous 
sources  of  error  and  the  technical  complications  sur- 
rounding these  two  methods  have  prevented  their  intro- 
duction into  clinical  medicine  and  they  need  not  be 
described. 

The  methods  which  are  in  use  to  determine  the  anti- 
toxic functional  power  of  the  liver  are  two  in  number. 
They  are  as  follows:  1.  The  Methylene  Blue  Test  of 
Chauffard  and  Castaigne.  2.  Estimation  of  Indica- 
nuria,  Spontaneous  and  Provocative. 

1.     Methylene  Blue  Test  of  Toxopexic  Function  of  the 
Liver.     Chauffard,  Castaigne  Test  26 

When  the  liver  cell  is  unable  to  properly  arrest  and 
fix  poisons,  it  reacts  to  the  passage  of  methylene  blue 

28  See  also  Estimation  of  Urinary  Toxicity  as  a  Test  of  Renal 
Function. 

""Presse  M6d.,  1898,  April  23;  Jour,  de  Physiol.  Path.,  1899, 
May.  See  also  Babaliantz,  These  de  Geneve,  1912. 


Tests  of  Liver  Function  37 

through  its  parenchyma  by  an  intermittent  elimina- 
tion. 

Test. — Inject  1  c.c.  of  5%  solution  of  methylene 
blue  subcutaneously.  Collect  and  examine  the  urine 
in  half  an  hour,  then  every  hour.  Normally  at  the 
end  of  half  an  hour  after  injection  the  urine  becomes 
colored,  the  color  rising  to  maximum  in  3  or  4  hours, 
disappearing  in  about  50  hours.  If  the  elimination 
when  it  commences  instead  of  being  continuous  occurs 
in  cycles,  that  is  intermittently,  the  test  is  positive  and 
may  indicate  hepatic  insufficiency. 

It  must  be  acknowledged  that  the  value  of  this  test 
is  greatly  diminished  by  the  fact  that  the  state  of 
renal  permeability  must  be  considered,  since  this  will 
have  a  predominant  influence  upon  the  quantity  and 
rapidity  of  elimination.  Where  this  factor  is  known 
the  test  may  be  of  value. 

Roche's  Modification  of  Chauffard's  Methylene  Blue 
Test. — In  this  test  the  methylene  blue  is  taken  inter- 
nally instead  of  being  given  hypodermically.  .002  gm. 
of  methylene  blue  is  swallowed  at  eight  o'clock  in  the 
morning  on  an  empty  stomach.  The  substance  is  given 
in  capsule.  The  urine  is  collected  every  four  hours  in 
separate  vessels.  If  the  urine  of  the  second  recipient 
is  clearly  colored  it  will  denote  inability  of  the  liver 
to  retain  the  pigment  and  consequent  hepatic  insuf- 
ficiency. Normally  this  amount  of  methylene  blue 
should  be  completely  arrested  and  fixed  by  the  liver 
so  that  no  coloring  matter  appears  in  the  urine  after 
its  administration.  If  the  test  is  positive,  the  urine, 
especially  that  passed  four  to  eight  hours  after  ad- 
ministration, will  be  colored  green. 

Unfortunately  the  condition  of  the  kidney  must  also 
be  reckoned  Avith  in  applying  this  test,  as  failure  of 


38      Manual  of  Vital  Function  Testing  Methods 

elimination  of  the  dye  may  be  due  to  renal  impermea- 
bility. 

The  same  remarks  with  respect  to  renal  permea- 
bility apply  in  interpreting  the  Roche  modification  as 
when  the  dye  is  given  by  hypodermic  injection.  It 
can  never  be  known  a  priori  whether  a  failure  of  elimi- 
nation is  due  to  renal  insufficiency  or  to  normal  fixa- 
tion of  the  dye  by  the  liver  cell.  In  other  words,  the 
state  of  the  kidney  function  must  be  previously  known 
or  ascertained. 

2.  Indicanuria  Spontaneous  and  Provocative  as  a 
Means  of  Testing  the  Integrity  of  Hepatic  Fixa- 
tion 

Spontaneous  Indicanuria. — It  has  been  urged  that 
the  normal  liver  is  always  capable  of  arresting  and 
destroying  indican  which  is  formed  in  the  intestine  as 
a  result  of  putrefaction  of  albuminoids.  Therefore 
the  spontaneous  presence  of  indican  in  the  urine  has 
been  held  to  be  evidence  of  hepatic  insufficiency. 

Provocative  Indicanuria — .001  gm.  of  indol  is  in- 
gested in  the  morning  on  an  empty  stomach.  The  urine 
is  collected  every  four  hours  and  examined  for  indican. 
The  individual  to  be  tested  should  be  put  on  a  milk 
diet  for  a  few  days  before  the  substance  is  ingested. 

TESTS    FOR    INDICAN    IN    THE    URINE 

Qualitative.-— The  principle  involved  is  to  decom- 
pose the  sodium  or  potassium  compound  of  indoxyl 
sulphuric  acid  present  in  the  urine  by  strong  HC1  and 
oxidizing  this  compound. 

Obermayer's  reagent  is  usually  employed.  This  con- 
sists of  strong  HC1,  sp.  gr.  1.19,  to  which  is  added  two 
parts  per  thousand  of  ferric  chloride.  The  liquid  is 


Tests  of  Liver  Function  39 

fuming  yellow  and  keeps  indefinitely. 

Precipitate  the  specimen  of  urine  to  be  tested  with 
a  small  amount  of  lead  acetate  or  subacetate,  avoiding 
excess,  and  filter.  This  removes  pigments.  15  c.c.  of 
filtered  urine  are  mixed  with  equal  quantity  of  Ober- 
mayer's  reagent  and  2  c.c.  of  chloroform  added.  Cork 
or  cap  the  tube  with  rubber,  and  slowly  invert.  The 
chloroform  takes  on  a  blue  color  whose  depth  will 
roughly  show  the  amount  of  indican  present. 

Quantitative.  —  Strauss'  2T  method  is  a  good  one. 
Twenty  c.c.  of  urine  are  mixed  with  5  c.c.  of  20%  lead 
acetate  solution  and  filtered.  Ten  c.c.  of  filtrate  (cor- 
responding to  8  c.c.  urine)  are  placed  in  a  small  gradu- 
ated separatory  funnel  and  mixed  with  10  c.c.  of  Ober- 
mayer's  reagent  (v.  s.). 

Five  c.c.  of  chloroform  are  added,  the  tube  corked 
and  gently  shaken.  This  is  repeated  in  two  minutes. 
Pour  the  chloroform  from  the  tube.  Add  5  c.c.  of 
chloroform  and  repeat  the  extraction.  Continue  until 
added  chloroform  remains  colorless. 

Two  c.c.  of  united  chloroform  extracts  are  put  in 
a  small  test  tube  of  same  diameter  as  tube  containing 
standard  solution.  Chloroform  is  added  drop  by  drop 
until  colors  are  matched,  against  white  background. 

The  standard  solution  is  made  by  dissolving  .001  gm. 
C.P.  indigotin  (Kahlbaum)  in  1000  c.c.  of  chloroform. 
Portion  is  sealed  in  test  tube  and  kept  in  the  dark. 

If  the  total  amount  of  chloroform  used  for  extrac- 
tion is  equal  to  a  and  the  amount  of  chloroform  used 
to  dilute  the  2  c.c.  to  the  color  of  the  standard  tube 
equals  x,  the  total  amount  of  chloroform  necessary  to 
dilute  all  the  chloroform  used  in  extraction  equals 


27Deutsch.  med.  Wchnsch.,  1902,  p.  299. 


40       Manual  of  Vital  Function  Testing  Methods 

The  total  number  of  c.c.  used  in  the  extraction  and 
in  the  dilution  of  the  extraction  mixture  represents, 
therefore,  a  bulk  containing  .001  gm.  of  indigo. 

In  normal  urines  5-10  c.c.  of  chloroform  are  usually 
all  that  is  required  to  extract  the  whole  amount. 

To  obtain  the  results  in  milligrams  it  must  be  con- 
sidered that  the  amount  of  indigo  extracted  was  from 
8  c.c.  of  urine. 


IV.  FUNCTIONAL  TESTS  TO  DETERMINE  DISTURBANCES 
OF  THE  SANGUINOPOIETIC  FUNCTION  OF  THE  LIVER 
CELL 

Some  results  of  practical  value  have  already  come 
from  tests  of  hepatic  function  based  upon  the  haemic 
activities  of  the  liver.  The  whole  question  of  the  rela- 
tion of  the  liver  to  the  biology  of  the  blood  is  very  com- 
plex and  not  completely  understood  at  the  present 
time ;  but  it  is  generally  agreed  that  the  liver  is  inti- 
mately concerned  in  the  elaboration  of  some  of  the 
constituents  of  the  blood,  particularly  fibrinogen  and 
certain  of  the  ferments. 

The  haemic  tests  so  far  proposed  have  dealt  with 
two  physiological  aspects  of  the  relation  between  the 
liver  and  blood :  first  coagulability  and  second  the 
presence  of  miscellaneous  ferments.  If  the  liver  is  in 
reality  the  principal  source  for  the  elaboration  of 
fibrinogen  any  notable  diminution  of  this  substance 
in  the  blood  will  indicate  a  diminution  of  the  func- 
tional integrity  of  the  liver  cells.  With  diminished 
fibrinogen  and  perhaps  also  fibrin  ferment,  a  delay  or 
deficiency  in  the  coagulability  of  the  blood  will  ensue. 

One  test  of  liver  function  will  therefore  consist  in 
estimating  the  coagulability  of  the  blood. 

With  respect  to  the  tests  for  ferments  in  the  blood 


Tests  of  Liver  Function  41 

it  may  be  said  that  the  estimation  of  lipase  is  so  far 
the  most  important.  The  liver  under  normal  circum- 
stances inhibits  the  formation  of  this  ferment  so  that 
hepatic  insufficiency  results  in  an  actual  increase  in 
the  amount  of  lypolytic  enzyme  in  the  blood. 

The  other  ferment  tests  of  hepatic  function  are  ap- 
parently too  subtle  and  uncertain  to  be  of  any  con- 
siderable practical  value. 

The  functional  tests  which  are  in  use  at  the  present 
day  to  determine  the  sanguinopoietic  capacity  of  the 
liver  are  as  follows:  1.  Estimation  of  blood  coagula- 
tion time,  and  estimation  of  fibrinogen.  2.  Estimation 
of  fibrinolysis  time.  3.  Estimation  of  the  amount  of 
lipase  in  the  blood. 

1.     Estimation  of  Blood  Coagulation  Time  as  an  Index 
of  Liver  Function 

Prolongation  of  coagulation  time  of  the  blood  is 
said  to  be  present  when  the  liver  is  physiologically  de- 
fective and  consequently  the  estimation  of  coagulation 
time  has  been  proposed  as  a  simple  and  effective  means 
of  determining  hepatic  insufficiency. 

Unfortunately  while  the  relation  of  normal  hepatic 
function  to  normal  coagulation  of  the  blood  is  un- 
doubtedly intimate  and  important,  it  is  also  true  that 
so  many  other  factors  besides  the  liver  enter  into  the 
physiology  of  blood  coagulation  as  to  materially  lessen 
its  importance  as  a  basis  for  functional  estimation. 

Coagulation  time  of  the  blood  has  also  been  sug- 
gested by  Tettinger  and  Bachrach  as  a  means  of  test- 
ing renal  function. 

Wright's  Method  of  Estimating  Coagulation  Time. 
—The  necessary  apparatus  consists  of  a  series  of  cap- 
illary tubes,  elastic  bands,  a  beaker,  a  jug  of  hot  and 


42      Manual  of  Vital  Function  Testing  Methods 

a  jug  of  cold  water,  a  watch  with  a  second  hand  and 
a  thermometer.  The  capillary  tubes  are  of  the  same 
caliber  and  are  provided  with  a  5  c.  mm.  mark.  The 
procedure  is  as  follows:  Clean  the  patient's  thumb 
with  ether.  Wrap  a  piece  of  elastic  tubing  round  the 
thumb  from  the  base  nearly  to  the  tip.  Puncture  the 
tip  of  the  thumb  with  a  sterile  surgical  needle.  Draw 
up  blood  to  the  mark  on  the  pipette.  It  is  not  essential 
to  obtain  the  exact  quantity  of  blood,  slight  variations 
in  the  amount  being  of  less  importance  than  rapid 
manipulation.  Note  the  exact  time  by  the  watch. 
Stretch  a  flat  elastic  band  over  the  ends  of  the  tube  to 
prevent  entrance  of  water.  Stand  the  tube  in  the 
beaker  filled  with  water  at  37°  C.  Stir  the  water  oc- 
casionally with  the  thermometer  and  keep  the  tem- 
perature constant  by  adding  hot  or  cold  water. 

Prepare  three  or  four  more  capillary  tubes  in  the 
same  way,  numbering  each  tube  and  taking  the  time  of 
each.  At  the  end  of  three  minutes  take  out  the  first 
tube  and  blow  out  the  blood.  Give  the  second  tube 
3}/o  minutes  and  if  the  blood  is  still  fluid  give  the  third 
tube  four  minutes  and  so  on.  The  tube  from  which 
the  blood  fails  to  be  expelled  by  blowing  gives  the  co- 
agulation time.  The  normal  time  for  blood  coagulation 
is  31/2  minutes. 

The  Fibrinogen  Test.  Whipple  Hormtz.28 — 20  c.c. 
of  oxalated  blood  plasma  are  heated  to  59°  C.  for  20 
minutes.  Fibrinogen  is  precipitated.  The  precipitate 
is  isolated  by  centrifugation,  washed  with  water,  alcohol 
and  ether,  dried  at  120°  C.  and  weighed.  A  rough  esti- 
mate of  the  amount  of  fibrinogcn  in  the  blood  is  made 
by  clotting  a  little  plasma  with  calcium,  testing  the 

28  Jour.  Exp.  Med.,  1911,  XIII,  p.  136;  also  Johns  Hopk.  Hosp. 
Bull.,   1913,  XXIV,  p.  207,  343. 


Tests  of  Liver  Function  43 

toughness  of  the  clot  with  a  glass  rod.     The  quantita- 
tive or  weighing  method  is,  however,  better. 

Normally  fibrinogen  exists  in  the  plasma  in  the  pro- 
portion of  .30  to  .40  gm.  per  100  c.c.  In  case  of  liver 
deterioration,  alteration  or  injury  the  amount  will 
be  found  diminished.  In  some  cases  of  cirrhosis  the  fibri- 
nogen content  has  been  found  very  low  (.05  gm.  or  less.) 

#.     Estimation  of  Fibrinolysis  Time  as  an  Index  of 
Hepatic  Function.     Goodpasture  Test  29 

Very  recently,  Goodpasture  has  called  attention  to 
the  interesting  and  important  fact  that  in  chronic, 
atrophic,  hepatic  cirrhosis  the  blood  possesses  the  power 
of  completely  digesting  the  clot  in  a  few  hours  at  body 
temperature. 

The  clot  in  normal  blood  remains  undigested  for 
days  and  sometimes  even  for  weeks.  Goodpasture  be- 
lieves that  the  dissolution  of  the  clot  is  due  to  an 
enzyme.  The  activity  of  this  enzyme  is  destroyed  by 
heat  and  inhibited  by  normal  serum.  The  fibrinogen 
content  of  the  blood  in  his  reported  cases  (four  in 
number)  was  below  normal.  He  suggests  premature 
digestion  of  clot  durante  vivo  may  account  for  the 
frequency  of  spontaneous  hemorrhage  in  atrophic 
cirrhosis.  The  Goodpasture  test  will,  in  all  likelihood, 
be  found  of  great  value  in  estimating  hepatic  insuf- 
ficiency in  chronic  cirrhosis.  It  will  be  interesting  to 
observe  what  the  test  for  fibrinolysis  will  show  in  early 
or  latent  cases  of  cirrhosis  as  well  as  in  hepatic  con- 
ditions generally. 

Technic  of  Goodpasture  Test. — Blood  is  drawn  from 
an  arm  vein  by  means  of  the  usual  technic.  The  coagu- 

29  Johns  Hopk.  Hosp.  Bull.,  1914,  XXV,  p.  330. 


44      Manual  of  Vital  Function  Testing  Methods 

lation  time  is  estimated.*  A  portion  of  blood  is  drawn 
into  1  Jo  solution  of  sodium  oxalate  to  prevent  clotting 
of  the  specimen.  This  last  is  centrifuged  and  20  c.c. 
of  supernatant  plasma  is  used  to  determine  fibrinogen 
content  if  this  is  desired.  Otherwise  the  entire  oxalated 
plasma  is  used  for  tests  of  coagulation  time  and  fibrin- 
olysis. 

In  testing  the  oxalated  plasma  for  coagulation  time, 
use  1  c-c.  of  plasma  -)-  1  gtt.  CaCl2  (1%). 

The  original  clot  from  the  drawn  blood  and  speci- 
mens of  clotted  oxalate  plasma  are  placed  in  the  ther- 
mostat at  37°.  They  are  examined  every  hour.  If  the 
test  is  positive,  the  blood  clot  liquefies  and  is  dissolved 
in  31/2  to  5  hours. 

In  negative  (normal)  cases  there  is  no  digestion  of 
the  clot  for  several  days,  even  where  no  aseptic  pre- 
cautions are  taken. 

3.     Estimation  of  Blood  Lipase  as  an  Index  of  Liver 
Function.     Whipple's  Test  30 

There  exists  normally  in  the  blood  a  lipolytic  fer- 
ment lipase.  The  percentage  of  lipase  in  normal  blood 
is  remarkably  uniform.  In  certain  diseases  of  the  liver 
this  ferment  has  been  found  to  increase  in  amount  indi- 
cating that  under  normal  circumstances  the  liver  in- 
hibits its  formation.  Any  considerable  increase,  there- 
fore, of  lipase  in  the  blood  has  been  held  to  indicate 
hepatic  insufficiency.  Whipple,  in  collaboration  with 
Mason  and  Peightal,  found  that  after  acute  injury  of 
the  liver  from  chloroform  there  was  always  found  an  in- 

*  For  other  methods  than  Wright's  consult  modern  laboratory 
manuals. 

30 Johns  Hopk.  Hosp.  Bull.,  1913,  XXIV,  p.  207;  ibid.,  343; 
ibid.,  357. 


Tests  of  Liver  Function  45 

crease  in  the  lipase  of  serum  or  plasma.  Sometimes  this 
rise  amounted  to  1—2  c.c.  of  1/10  normal  acid.  Inas- 
much as  the  content  of  lipase  may  increase  five  to  eight 
times  the  normal  under  certain  conditions  of  hepatic 
disease  it  was  naturally  suggested  as  a  test  of  hepatic 
insufficiency. 

The  value  of  the  test  is  chiefly  qualitative  rather  than 
quantitative.  It  has  been  found  of  especially  positive 
value  in  suspected  eclampsia,  chloroform  poisoning,  yel- 
low atrophy  and  cholangitis.  In  cirrhosis  of  the  liver 
there  may  be  a  subnormal  lipase. 

Tests  for  Lipase  in  the  Blood.  Lowerihart's 31 
Method  of  Estimating  Lipase  Is  Usually  Employed. — 
Blood  serum  is  collected  in  four  tubes  and  a  little 
toluene,  .3  c.c.,  is  added  to  prevent  microbic  contami- 
nation. Each  tube  contains  1  c.c.  plasma  or  serum 
diluted  with  4  c.c.  of  distilled  water. 

Two  of  these  tubes  are  used  as  controls.  To  the 
others  a  little  ethyl  butyrate  (butyric  ether),  .26  c.c., 
is  added.  The  four  tubes  are  shaken,  corked  and  put  in 
the  thermostat  at  38°  for  18  to  24  hours. 

At  the  end  of  this  time  the  two  control  tubes  are  ex- 
amined for  their  normal  alkalinity  by  means  of  deci- 
normal  acid  solution.  The  other  two  tubes  are  titrated 
for  free  butyric  acid  by  decinormal  alkali  solution. 

The  total  lipolytic  activity  is  measured  by  adding 
the  two  figures,  since  the  butyric  acid  formed  had  to 
first  neutralize  the  normal  alkalinity  of  the  serum. 

The  exact  method  is  as  follows :  After  incubation 
the  tubes  are  cooled  in  ice  water,  3  drops  of  azolitmin 
added  and  then  titrated  in  pairs  to  a  neutral  reaction, 
using  Vio  normal  acid  and  alkali.  The  two  control 
tubes  usually  show  the  blood  alkalinity  to  be 
.1  c.c.  Vio  normal  acid  and  the  butyrate  tubes  show 

81  Amer.  Jour.  Physiol.,  1902,  VI,  p.  331. 


46      Manual  of  Vital  Function  Testing  Methods 

the  acid  production  to  be  .1  to  .2  c.c.  above  the  neutral 
point.  This  means  that  the  total  lipolytic  activity  is 
.2  to  .3  c.c.  Vio  normal  solution,  that  the  plasma 
lipase  has  split  up  the  ethyl  butyrate  to  this  amount. 
Normal  plasma  lipase  is  then  in  terms  of  Vio  normal 
acid  equal  to  .20  to  .30  c.c. 

Ghedini's  Test.^2 — This  consists  in  an  estimation  of 
the  power  of  the  blood  serum  to  convert  glycogen  into 
glucose.  A  reducing  ferment  supposed  to  be  formed 
by  the  liver  cells  effects  the  conversion. 

The  Test. — Blood  serum  to  be  examined  is  added  to 
a  solution  of  glycogen.  Scrum  from  a  known  normal 
person  is  similarly  treated  and  used  as  a  control. 

To  both  tubes  is  added  a  little  sodium  hydroxide, 
then  potassium  sulphocyanide,  and  the  solutions  fil- 
tered and  examined  with  the  polariscope. 

If  there  is  hepatic  insufficiency  the  rotatory  power 
of  the  serum  will  be  less  than  the  normal  control. 

The  factors  upon  which  this  test  are  founded  are 
rather  subtle  and  imperfectly  understood ;  indeed  it  is 
by  no  means  accepted  that  the  liver  is  the  unique  or 
even  the  most  important  source  of  the  ferment  which 
affects  the  conversion  of  glycogen  into  glucose. 

4-     Application  of  Abderhalden's  33  Method  to  Estima- 
tion of  Sanguinopoietic  Functions  of  the  Liver 

Recently  it  has  been  held  that  destruction  of  liver 
parenchyma  by  disease  (autolysis)  gives  rise  to  the 
presence  of  an  excess  of  protcolytic  ferments  in  the 
blood  serum  and  this  fact  has  formed  a  basis  for  test- 

32  Gazz.  degli  ospcdali,  Milan,  Jan.  12. 

33  See  Breitmann,  Zentrbl.  f.  innere  Med.,  XXIV,  1913,  p.  857. 


Tests  of  Liver  Function  47 

ing  the  functional  capacity  of  the  liver. 

The  technic  of  the  method  is  too  complicated  to 
admit  of  its  use  in  clinical  practice  and  the  results  ob- 
tained are  as  yet  too  meagre  to  justify  any  conclusions 
as  to  its  value. 


V.  FUNCTIONAL,  TESTS  TO  DETERMINE  DISTURBANCE  OF 
THE  EXOCRINOUS  OR  BILIARY  FUNCTION  OF  THE 
LIVER 

Bile  is  partly  a  secretion  and  party  an  excretion,  for 
it  not  only  plays  a  role  in  certain  digestive  processes, 
notably  the  splitting  or  absorption  of  fats,  but  it  also 
contains  certain  waste  products  which  escape  in  the 
feces.  It  is  important  to  remember,  however,  that  cer- 
tain constituents  secreted  and  excreted  in  the  bile  are 
reabsorbed  by  the  intestine  and  carried  back  by  the 
blood  stream  to  the  liver. 

Perfectly  fresh  hepatic  bile,  in  contradistinction  to 
bile  in  the  gall  bladder,  contains  one  pigment  only, 
namely,  bilirubin,  and  from  this  pigment  others  are 
gradually  formed  by  processes  of  oxidation.  Fresh 
human  bile  from  the  hepatic  duct  is  golden  yellow  in 
color  but  becomes  olive  brown  to  grass  green  after  re- 
maining in  the  gall  bladder  and  cystic  duct,  because  of 
the  presence  of  biliverdin,  which  is  an  oxidation  product 
of  bilirubin. 

It  is  now  universally  accepted  that  the  bile  pigment 
bilirubin  originates  from  the  disintegrated  hemoglobin 
of  the  red  blood  corpuscles.  When  these  break  up 
their  contained  pigment  is  carried  to  and  fixed  by  the 
liver,  where  it  is  converted  into  an  iron-free  pigment, 
bilirubin. 

It  appears  that  the  power  of  transforming  blood 
pigment  into  bilirubin  is  not  exclusively  the  property 


48      Manual  of  Vital  Function  Testing  Methods 

of  the  liver  cell,  since  in  old  blood  extravasions  any- 
where in  the  body  a  substance,  haematoidin,  is  found 
which  is  chemically  identical  with  bilirubin.  Under 
ordinary  physiological  conditions,  however,  the  liver 
seems  to  be  the  only  place  in  the  body  where  bilirubin 
is  formed.  It  is  not  known  whether  the  actual  dis- 
integration of  red  corpuscles  is  confined  to  the  liver, 
but  certainly  this  organ  has  the  unique  power  of  fixing 
the  hemoglobin  set  free  by  haemolysis,  retaining  its 
iron  and  converting  it  into  bilirubin. 

Under  normal  conditions  bilirubin  does  not  appear 
in  the  feces,  but  in  its  place  is  found  a  reduction  prod- 
uct which  is  known  as  urobilin  (stercobilin).  The  reduc- 
tion of  bilirubin  to  urobilin  takes  place  in  the  intestine 
from  nascent  hydrogen  liberated  by  bacterial  action. 
Part  of  this  urobilin  formed  in  the  intestine  escapes  in 
the  stools.  Another  portion  is  reabsorbed  by  the  in- 
testinal mucosa  as  a  protochrome, — urobilinogen.  Part 
of  this  substance  is  eliminated  in  the  feccs.  The  re- 
mainder passes  back  thro  the  portal  circulation  to 
the  liver,  where  it  is  changed  back  into  bilirubin  to  be 
again  reexcreted  by  the  bile  when  the  cycle  is  re- 
peated. 

A  very  minute  amount  of  the  urobilinogen  absorbed 
by  the  bowel  escapes  in  the  urine.  Under  normal  con- 
ditions this  quantity  is  very  small. 

Soon  after  urobilinogen  is  eliminated  by  the  urine, 
it  changes  to  urobilin  so  that  the  urobilin  is  not  present 
in  freshly  passed  urine  but  only  appears  from  the  break- 
ing down  of  urobilinogen  by  light  and  air. 

Urobilin  was  recognized  as  a  constitutent  of  patho- 
logical urines  long  before  urobilinogcn,  from  which  it 
is  formed  by  oxidation,  was  discovered. 

Urobilinuria  and  urobilinogenuria  may  therefore  be 
regarded  as  practically  identical  and  due  to  the  same 


Tests  of  Liver  Function  49 

substance  in  different  forms.  The  pathological  causes 
of  both  are  the  same. 

It  has  been  known  for  a  long  time,  however,  that 
urobilin  appears  in  the  urine  in  a  comparatively  large 
number  of  pathological  conditions,  among  which  may 
be  mentioned  the  infectious  diseases,  particularly  ma- 
laria and  pneumonia,  cirrhosis  of  the  liver,  lead  poison- 
ing, decompensated  heart  disease,  pernicious  anaemia, 
pulmonary  infarction  and  visceral  hemorrhages.  Like- 
wise certain  drugs  and  poisons  are  known  to  produce 
urobilinuria.  In  obstructive  jaundice,  it  often  appears 
in  the  urine  before  bilirubin  and  may,  in  fact,  alternate 
with  this  substance.  Urines  which  contain  much  uro- 
bilin present  a  dark  yellow  color  which  may  be  imparted 
to  the  foam  on  shaking.  They  are  thus  quite  like  or- 
dinary icteric  urines. 

The  hepatic  conditions  in  which  urobilin  appears  in 
the  urine  fall  into  two  groups:  1.  Mechanical  inter- 
ference with  biliary  flow  in  the  ducts.  2.  Insufficiency 
of  the  liver  cell.  In  the  first  group,  if  the  obstruction 
is  absolute  as  in  some  cases  of  stone,  no  bile  reaches 
the  intestine  and  no  urobilin  is  formed,  hence  no  uro- 
bilinogen  appears  in  the  blood  or  urine.  If  the  ob- 
struction remains  complete  the  bile  pigment  bilirubin 
begins  to  be  absorbed  by  the  blood  and  excreted  in 
the  urine.  If  the  occlusion  of  the  ducts  is  only  partial, 
some  bile  reaches  the  intestine,  urobilin  is  formed,  ab- 
sorbed and  may  appear  as  urobilinogen  in  the  urine. 
On  removal  of  the  obstruction  the  full  flow  of  bile  in 
the  intestine  is  resumed.  The  functional  activity  of 
the  liver  is  sufficient  to  eliminate  the  urobilinogen 
brought  to  it  by  the  blood  from  the  intestine  and  hence 
there  is  no  call  for  its  elimination  by  the  kidney  and 
it  becomes  reduced  to  a  mere  trace  in  the  urine  or  com- 
pletely disappears  therefrom. 


50      Manual  of  Vital  Function  Testing  Methods 

As  a  sign  of  liver  insufficiency  urobilinogenuria  may 
be  absolute  or  relative.  Absolute  when  the  liver  paren- 
chyma is  totally  unable  to  eliminate  urobilinogen  and 
allows  it  to  get  into  the  blood;  relative  when  an  ex- 
cessive breaking  down  of  red  corpuscles  anywhere  in 
the  body  overwhelms  the  liver  with  pigment  which  the 
cells  are  unable  completely  to  convert  into  bilirubin. 
In  other  words,  if  the  liver  is  insufficient  it  will  be  un- 
able to  excrete  increased  amounts  of  urobilinogen 
whether  derived  from  intestinal  urobilin  or  from  blood 
pigments.  In  either  case  there  will  be  an  increase  or 
accumulation  of  urobilinogen  in  the  blood  and  it  will 
appear  in  measurable  amounts  in  the  urine. 

Icterus  with  the  appearance  in  the  urine  of  normal 
bile  pigment  (bilirubin)  may  be  regarded  as  a  further 
step  in  such  a  pathological  process.  Here  the  defect 
of  excretory  function  of  the  liver  is  greater  because 
of  actual  inflammatory  obstruction  of  the  biliary  tract. 
Jaundice,  as  is  well  known,  is  the  result  of  the  absorp- 
tion into  the  blood  of  the  bile  pigment  bilirubin.  Jaun- 
dice, whether  obstructive  or  toxemic,  is  always  due  to 
some  lesion  of  the  biliary  excretory  passages  by  which 
the  flow  of  bile  into  the  intestine  is  diminished  or  pre- 
vented and  is  always  accompanied  by  some  inflam- 
matory state  of  the  biliary  tubules.  Icterus,  when 
well  marked,  becomes  clinically  quite  evident  from  the 
discoloration  of  tissue  which  results.  The  demonstra- 
tion of  bilirubin  in  the  urine  is  then  superfluous.  In 
such  an  event,  icterus  becomes  an  element  in  the  semi- 
ology  of  hepatic  disease  and  has  to  be  evaluated  with 
other  symptoms  in  making  a  diagnosis. 

The  presence  of  small  quantities  of  bile  pigment 
(bilirubin)  in  the  urine  is,  however,  an  earlier  sign  of 
exocrinous  hepatic  insufficiency  than  icterus.  For  this 
reason  the  tests  for  bile  pigment  in  the  urine  become 


Tests  of  Liver  Function  51 

tests  to  a  certain  extent  at  least  of  hepatic  disease  and 
perhaps  insufficiency. 

To  summarize  the  above  facts  in  their  relation  to 
the  estimation  of  the  external  secretory  function  of 
the  liver  it  may  be  said  that  disturbances  of  this  func- 
tion are  identified  by  tests  which  disclose  the  presence 
in  the  urine  of  the  three  substances  above  mentioned, 
namely,  urobilinogen,  urobilin  and  bilirubin ;  the  tests 
for  these  substances  will  therefore  be  given  together 
with  special  data  bearing  upon  their  individual  sig- 
nificance. 

There  is,  however,  another  way  by  which  the  total 
power  of  the  liver  to  carry  on  its  external  secretory 
function  may  be  judged.  This  consists  theoretically, 
in  finding  a  substance  which  if  injected  into  the  circula- 
tion will  be  eliminated  exclusively  by  the  liver.  It 
was  only  in  recent  years  that  such  a  substance  was  dis- 
covered, phenoltetrachlorphthalein. 

Tests  to  determine  the  status  of  the  excretory  func- 
tional power  of  the  liver  may,  therefore,  be  properly 
divided  into  two  categories : 

1.  Tests  for  urobilinogen,  urobilin  and  bilirubin  in 
the  urine  with  the  interpretation  of  results  in  reference 
to  hepatic  insufficiency.  2.  Tests  to  determine  the 
global  capacity  of  the  liver  to  eliminate  foreign  sub- 
stances. In  this  category  there  is  but  one  test  so  far 
devised,  namely  that  of  phenoltetrachlorphthalein. 

1.  Tests  for  Urobilinogen,  Urobilin  and  Bilirubin 
in  the  Urine.  Interpretation  of  Results  with  Refer- 
ence to  Hepatic  Insufficiency 

The  Urobilinogen  Test.  Ehrlich's  Test.34— The  Ben- 
zaldehyde  Reaction. — While  investigating  the  aniline 

34Wien.  med.  Wchnschr.,  1901,  XV;  Munch,  med.  Wchnschr., 
1901,  XV. 


52      Manual  of  Vital  Function  Testing  Methods 

dyes  for  their  effects  upon  trypanosomes,  Ehrlich  found 
that  the  addition  of  paradimethylamidobenzaldehyde  to 
certain  fresh  urines  produced  a  bright  red  coloration. 
This  was  in  1901.  In  1903  Pappenheim  35  called  atten- 
tion to  the  fact  that  the  reaction  occurred  only  in  those 
urines  which,  on  standing,  gave  the  reaction  of  urobilin. 
In  the  same  year  Neubauer  36  demonstrated  that  the 
reaction  was  due  to  urobilinogen,  a  colorless  chromogen 
which  gradually  becomes  converted  into  urobilin. 

Technic. — The  test  is  very  simple.  Add  to  fresh 
urine  in  a  test  tube  several  drops  of  Ehrlich's  reagent. 
The  reagent  is  as  follows : 

Paradimethylaminobenzaldehyde  ...  8  gms. 
Concentrated  hydrochloric  acid  ....  80  gms. 
Distilled  water 200  gms. 

If  urobilinogen  is  present  a  red  color  appears.  The 
color  reaction  in  the  cold  urine  is  of  pathological  sig- 
nificance only  when  a  distinct  scarlet  color  is  obtained. 

There  are  a  few  sources  of  possible  error.  The  in- 
gestion  of  hexamethylamine  or  antipyrine  may  cause 
the  same  reaction.  The  presence  of  acetone  in  the 
urine  must  also  be  excluded  as  it  produces  a  similar 
coloration. 

If  the  reaction  persists  after  free  purgation  it  is 
more  significant.  The  reaction  is  not  constant  in  all 
conditions  in  which  it  has  been  found  because  the  liver 
may  be  able  to  excrete  enough  urobilinogen  to  prevent 
its  appearance  in  the  blood  and  urine. 

Urobilinogen  has  been  found  in  the  urine  in  many 
pathological  conditions,  chief  of  which  are  cirrhosis  of 
the  liver,  cholangitis,  infectious  diseases,  heart  diseases 

80  Berl.  klin.  Wchnschr.,  1903,  II,  p.  42. 

36  Sitz.  d.  Gesell.  f.  Morph.  u.  Physiol.,  Munich,  1903,  July,  H.  ii. 


Tests  of  Liver  Function  53 

in  the  stage  of  decompensation,  pernicious  anaemia,  pul- 
monary infarction  and  visceral  hemorrhage. 

Ehrlich's  test  has  been  highly  recommended  as  a  clin- 
ical method  for  determining  hepatic  insufficiency  by 
Miiller,  Bauer,  Neubauer,  Hilderbrand  and  others.  It 
has  been  regarded  by  some  observers  as  an  adequate  and 
infallible  criterion  of  hepatic  function.  Some  observers 
have  claimed  for  it  a  prognostic  significance.  All  of 
these  contentions  have  been  found  to  overstate  the  facts. 

The  presence  of  urobilinogen  in  considerable  quan- 
tity in  the  urine  may  indicate  that  there  is  a  partial 
interruption  in  the  biliary  excretion  and  that  some  of 
the  intestinal  urobilin  absorbed  into  the  blood  is  not 
being  thrown  off  by  the  liver.  The  primary  cause  may 
be  either  a  disorder  of  the  liver  cells  or  a  congestion  or 
toxemic  obstruction  of  the  biliary  channels. 

The  discovery  of  a  persistent  urobilinogenuria  should 
therefore  point  to  a  careful  study  of  the  hepatic  func- 
tions by  all  known  means.  If  hepatic  insufficiency  can 
be  ruled  out  the  only  remaining  explanation  is  that 
excessive  destruction  of  the  blood  corpuscles  is  taking 
place  somewhere  in  the  body. 

Recently  rather  strong  criticisms  of  Ehrlich's  test 
have  appeared.  Wilbur  and  Addis  37  in  1913  stated 
that  they  do  not  believe  it  constitutes  a  reliable  criterion 
of  hepatic  function.  This  opinion  has  been  reiterated 
by  Chesney,  Marshall,  and  Rowntree,38  last  year.  All 
these  authors  maintain  that  observations  on  a  single 
or  24-hour  specimen  of  urine  have  no  significance.  That 
great  variations  appear  from  day  to  day  and  that 
only  when  repeated  tests  are  made  covering  a  period  of 
two  weeks,  controlled  by  studies  of  urobilin  content  in 
the  feces,  can  the  results  be  accepted. 

87  Arch,  of  Int.  Med.,  1913,  Feb.,  p.  235. 

38  Jour.  Amer.  Med.  Assn.,  1914,  LXXIII,  p.  1533. 


54      Manual  of  Vital  Function  Testing  Methods 

The  simplicity  of  Ehrlich's  test  will  insure  for  it  a 
permanent,  if  not  paramount,  place.  It  must  always 
be  remembered  that  only  a  persistent  and  well-marked 
urobilinogenuria  is  to  be  regarded  clinically  as  sig- 
nificant. 

A  well-marked  and  lasting  reaction  appears  to  in- 
dicate one  of  two  things,  an  hepatic  insufficiency  or 
excessive  hemolysis.  There  is  nothing  in  the  test  itself 
to  enable  a  differentiation  between  the  two  to  be  made. 
The  test  is  therefore  of  some  importance  when  regarded 
only  as  a  corroborative  sign  of  insufficiency  of  the 
excretory  function  of  the  liver. 

Tests  for  Urobilin. — First  add  to  the  urine  a  few 
drops  of  10%  solution  of  zinc  chloride  and  enough  am- 
monia to  dissolve  the  precipitate.  Filter  into  a  test 
tube  and  hold  same  against  a  dark  background ;  a  green 
fluorescence  denotes  urobilin.  Equal  quantities  of  1% 
solution  of  zinc  acetate  and  urine  may  be  used  in  the 
first  part  of  the  test.  The  fluorescence  may  be  made 
more  visible  by  concentrating  light  on  the  tube  with  a 
lens. 

Another  and  perhaps  more  delicate  method  of  de- 
tecting urobilin  is  to  extract  50  c.c.  of  urine  with  50  c.c. 
of  pure  ether.  Pour  off  the  ether  into  a  tube  and  evap- 
orate. Dissolve  the  brown  residue  in  a  little  strong 
alcohol.  The  solution  will  be  pale  yellow  with  a  green 
fluorescence  if  urobilin  is  present. 

A  third  method  is  to  acidify  20  c.c.  of  urine  with 
several  drops  of  HC1.  Shake  gently  with  5  c.c.  of  amyl 
alcohol.  This  extracts  the  pigment  and  shows  a  bright 
green  fluorescence  when  treated  with  an  alcoholic  solu- 
tion of  zinc  chloride  and  a  little  ammonia.  By  trans- 
mitted light  the  amyl  alcohol  is  a  faint  pink  shade. 

The  most  rapid  method  of  testing  for  urobilin  is  by 


Tests  of  Liver  Function  55 

the  use  of  the  pocket  spectroscope.  If  the  urine  is  dark 
it  should  be  diluted.  The  characteristic  spectrum  band 
is  seen  between  the  green  and  blue,  between  the  lines 
C  and  F. 

Tests  for  Bilirubin. — The  tests  usually  employed  are 
those  of  Gmelin,  Rosenbach,  Huppert  and  Smith. 

Gmelin's  Test.— The  urine  is  treated  with  sufficient 
concentrated  HNO3  containing  a  trace  of  nitrous  acid, 
sufficient  to  form  a  layer  beneath.  If  bilirubin  is  pres- 
ent there  will  be  a  play  of  colors  at  the  zone  of  contact 
from  yellow  through  green,  blue,  violet,  red  and  orange. 
The  green  will  lie  nearest  the  urine  and  the  orange  in 
the  upper  acid. 

Rosenbach' 's  Test.— Filter  the  urine  through  Swedish 
filter  paper ;  apply  a  drop  of  HNO3  containing  a  trace 
of  nitrous  acid  upon  the  paper.  The  play  of  colors 
above  mentioned  under  Gmelin's  test  will  appear. 

Huppert' s  Test. — Precipitate  the  urine  with  barium 
chloride  and  ammonia.  The  precipitate  is  washed  with 
water.  Wash  the  precipitate  with  alcohol  into  alcohol 
acidulated  with  sulphuric  acid.  Boil  for  a  time.  If 
bilirubin  is  present  an  emerald  green  color  will  appear. 

Smith's  Test. — A  small  amount  of  urine  is  placed  in 
a  test  tube  and  overlaid  with  a  few  c.c.  of  tincture  of 
iodine  diluted  with  alcohol  1 :10.  If  bilirubin  is  present 
a  distinct  emerald  green  ring  will  develop  at  the  zone  of 
contact. 


2.     Tests   to   Determine  the  Global  Capacity  of  the 
Liver  to  Eliminate  Foreign  Substances 

The  Phenoltetrachlorphthalein  Test  of  Liver  Func- 
tion.    Rowntree,  Horwitz,  and  Bloomfield  Test. — Phe- 


56      Manual  of  Vital  Function  Testing  Methods 

noltetrachlorphthalein  was  originally  studied  pharma- 
cologically by  Abel  and  Rowntree  39  in  1909.  It  was 
proposed  in  1913  as  a  test  for  functional  capacity  of 
the  liver  by  Rowntree,  Horwitz,  and  Bloomfield.  (Johns 
Hopk.  Hosp.  Bull.,  1913,  XXIV,  p.  327.)  Important 
experimental  work  was  done  on  the  drug  in  1913  to 
determine  its  behaviour  in  different  liver  injuries,  by 
Whipple,  Mason  and  Peightal,40  and  by  Whipple, 
Peightal  and  Clark.41 

Great  interest  is  attached  to  the  phenoltetrachlor- 
phthalein  test  for  liver  function ;  first,  because  it  bids 
fair  to  become  the  most  satisfactory  test  for  the  pur- 
pose yet  devised,  and,  secondly,  because  all  the  work 
upon  it  has  been  done  in  America. 

Professors  Orndorff  and  Black  42  of  Cornell  Univer- 
sity were  the  first  to  make  the  substance  in  1909.  The 
pharmacological  investigations  of  Abel  and  Rowntree 
included  a  study  of  phenolphthalein  together  with  the 
new  synthetic  phthaleins,  with  special  reference  to  their 
behaviour  as  purgatives.  They  found  that  phenolphtha- 
lein and  its  halogen  substitution  products,  of  which 
phenoltetrachlorphthalein  is  one,  do  not  differ  greatly 
in  their  physiological  action.  They  are  nonirritant  to 
mucous  membranes  and  subcutaneously  when  injected  in 
oil.  They  are  of  low  toxicity  and  possess  no  bacteri- 
cidal action. 

Both  phthaleins  are  laxative  when  given  by  mouth, 
subcutaneously  or  intravenously.  When  an  oily  solu- 
tion of  phenoltetrachlorphthalein  (.4  gm.)  is  injected 
under  the  skin  of  dogs  or  human  beings  a  laxative  action 
is  induced  which  continues  from  4  to  6  days.  When  the 

80  Jour.  Pharmacol.  and  Expcr.  Therap.,  1909,  I,  p.  231. 
"Johns  Hopk.  Bull.,  1913,  XXIV,  p.  207. 
"Johns  Hopk.  Bull.,  1913,  XXIV,  p.  343. 
0  Amer.  Chem.  Jour.,  XLI,  1909,  p.  349. 


Tests  of  Liver  Function  57 

tetrachlorphthalein  is  given  subcutaneously  it  escapes 
from  the  body  exclusively  in  the  bile.  When  the  same 
substance  is  given  by  mouth  it  is  not  absorbed.  After 
subcutaneous  administration  of  phenoltetrachlorphtha- 
lein  the  drug  escapes  dissolved  in  the  bile  and  becomes 
later  absorbed  by  the  mucous  membrane  of  the  large 
intestine. 

These  facts  form  the  physiological  basis  for  the  phe- 
noltetrachlorphthalein  test.  The  drug  is  eliminated  ex- 
clusively, or  practically  so,  in  the  bile,  and  since  this 
excretion  can  be  hurried  through  by  purgatives,  no  time 
will  be  given  for  its  absorption,  and  thus  the  actual 
amount  of  the  drug  eliminated  may  be  found. 

The  experimental  work  done  by  Whipple,  Mason  and 
Peightal,  and  by  Whipple,  Peightal  and  Clark  has 
established  the  fact  that  there  is  a  striking  parallelism 
in  animal  observations  between  the  amount  of  experi- 
mental liver  injury  produced  and  the  amount  of  phtha- 
lein  eliminated. 

Their  method  of  determining  this  fact  was  as  follows : 
Female  dogs  were  used  because  of  ease  of  catheteriza- 
tion.  The  dogs  were  given  intravenously  .1  gm.  of  the 
phthalein  when  weighing  between  10-20  pounds ;  .2  gm. 
when  weighing  over  20  pounds.  The  injection  was  given 
in  the  forenoon  and  200-300  c.c.  of  water  administered 
by  stomach  tube.  After  5  or  6  hours  the  urine  was  col- 
lected and  magnesium  sulphate  and  croton  oil  given  to 
produce  several  semi-fluid  stools.  The  feces  were  col- 
lected next  morning.  The  total  feces  were  then  diluted 
to  1  to  2  liters.  The  mixture  was  made  alkaline  with 
5-10  c.c.  of  40%  solution  of  sodium  hydroxide  and 
shaken  until  uniform.  One  tenth  of  this  quantity  was 
taken  and  diluted  to  500  c.c.  with  water,  3  to  4  c.c.  of 
40%  solution  sodium  hydroxide  added  and  the  mixture 
thoroughly  shaken.  Of  this  second  solution  100  c.c. 


58      Manual  of  Vital  Function  Testing  Methods 

were  precipitated  with  5  c.c.  of  saturated  solution  of 
basic  lead  acetate.  After  a  few  seconds  a  curdy  pre- 
cipitate fell.  The  solution  was  made  up  to  200  c.c. 
with  water  containing  4  c.c.  of  40 c/o  solution  sodium 
hydroxide.  On  standing,  the  supernatant  fluid  showed 
a  clear  phthalein  color.  This  was  filtered  and  the  clear 
solution  read  off  in  a  colorimeter  against  a  standard 
solution  .01  gm.  phthalein  to  the  liter. 

In  the  hands  of  its  authors,  this  method  gave  pretty 
uniform  results;  on  normal  dogs  the  amount  excreted 
being  35  to  50%  with  .1  gm.  injection  and  40  to  50% 
with  .2  gm.  injection.  The  drug  did  not  appear  in  the 
urine.  About  10-15%  of  the  phthalein  injected  was 
lost  from  the  time  of  the  injection  to  that  of  its  being 
poured  out  by  the  bile  into  the  intestine.  This  shows 
that  the  liver  is  quite  specifically  concerned  in  the  elim- 
ination of  the  substance,  phenoltetrachlorphthalein. 

Whipple  and  his  collaborators  found  that  when  the 
liver  parenchyma  is  artificially  injured,  as  by  chloro- 
form, phosphorus  or  hydrazinc,  there  is  a  very  notable 
drop  in  the  output  of  the  substance  in  the  feces  down 
to  20  or  10%  or  even  a  mere  trace.  The  phthalein  then 
begins  to  be  excreted  by  the  urine.  When  the  hepatic 
lesion  improves,  the  phthalein  output  in  the  bile  in- 
creases toward  normal.  The  normal  output  of  phe- 
noltetrachlorphthalein in  dogs  is  45%  of  the  amount 
injected.  The  drop  in  phthalein  output  is  always  pro- 
portional to  the  extent  of  liver  injury.  If  the  injury  is 
grave  enough  to  produce  death,  the  phthalein  output 
falls  to  zero.  In  some  instances  as  the  effects  of  the 
hepatic  injury  are  spontaneously  repaired,  there  may 
be  an  actual  increase  of  phthalein  output  even  above 
normal,  a  hypersecretion  of  phthalein  as  it  were. 

Besides  injury  to  the  liver  parenchyma  by  poisons, 
the  above  investigators  found  that  severe  circulatory 


Tests  of  Liver  Function  59 

disturbances  artificially  produced  are  followed  by  a 
drop  in  the  phthalein  output.  Actual  destruction  of 
liver  parenchyma  produces  similar  results. 

In  experimental  obstructive  icterus  there  is,  of  course, 
no  phthalein  output,  since  none  of  the  drug  reaches  the 
intestine.  In  experimental  hematogenous  icterus  there 
is  no  modification  of  phthalein  output. 

The  experimental  studies  so  far  performed  indicate 
that  the  phenoltetrachlorphthalein  will  be  valuable  from 
a  quantitative  as  well  as  a  qualitative  standpoint  in 
the  estimation  of  insufficiencies  of  liver  function. 

The  clinical  application  of  phenoltetrachlorphthalein 
as  a  test  for  hepatic  function  was  first  worked  out  by 
Rowntree,  Horwitz  and  Bloomfield. 

We  owe  to  Rowntree  the  suggestion  that  the  specific- 
ity of  the  liver  in  excreting  phenoltetrachlorphthalein 
analogous  to  that  of  the  kidney  towards  phenolsulphon- 
phthalein  would  indicate  that  estimations  in  man  of 
the  quantity  of  dye  excreted  by  the  liver  after  an  in- 
travenous injection  ought  to  afford  a  practical  clinical 
method  of  determining  the  functional  capacity  of  the 
liver. 

It  will  thus  be  seen  that  the  phenoltetrachlorphthalein 
test  of  Rowntree,  Horwitz  and  Bloomfield  is  founded 
upon  rational  theoretical  considerations  and  that  it  was 
subjected  to  a  very  rigid  experimental  investigation. 

Technic  of  Phenoltetrachlorphthalein  Test.  —  An 
aqueous  solution  of  the  disodium  salt  is  used.  It  is  pre- 
pared by  placing  2.5  gms.  of  phenoltetrachlorphtha- 
lein in  a  200  c.c.  Erlenmeyer  flask  with  5  c.c.  of  2/n 
NaOH  solution  and  45  c.c.  of  freshly  distilled  water. 
This  is  boiled  under  a  reflux  condenser  for  20  minutes. 
The  solution  is  filtered  into  a  100  c.c.  flask.  This  solu- 
tion is  of  5%  strength  and  is  approximately  isotonic 


60      Manual  of  Vital  Function  Testing  Methods 

with  blood.  It  is  intensely  purplish  red  in  color.  Since 
the  phthalein  is  precipitated  by  CO2  in  the  atmosphere 
it  will  not  keep  more  than  a  few  days,  hence  requires 
to  be  freshly  prepared  for  use.  The  patient  is  given 
two  compound  cathartic  pills  the  night  before  the  test 
is  applied. 

In  making  the  test  8  c.c.  of  the  solution  which  will 
contain  about  400  milligrams  of  tetrachlorphthalein  are 
measured.  It  has  been  found  that  this  amount  is  never 
followed  in  normal  persons  with  the  excretion  of  any 
dye  in  the  urine  and  is  sufficient  to  produce  an  intense 
color  in  the  final  preparation  of  the  feces.  The  8  c.c. 
is  given  intravenously  as  follows,  of  course  under  strict 
aseptic  precautions : 

A  funnel  with  properly  connected  intravenous  system 
is  filled  with  freshly  distilled  water  or  salt  solution  and 
the  flow  into  the  vein  is  started.  When  this  is  well 
established,  the  phthalein  solution  is  added.  Fifty  to 
100  c.c.  of  water  are  used  and  the  phthalein  solution  is 
washed  in  with  freshly  distilled  water  until  the  fluid 
entering  the  vein  is  clear.  About  a  quarter  of  an  hour 
is  required  for  the  injection. 

After  the  injection,  the  patient  is  given  another  pur- 
gative, usually  two  compound  cathartic  pills,  and  this 
dose  is  repeated  the  following  morning  if  the  bowels  are 
not  running  freely.  The  stools  are  collected  for  48 
hours  in  a  covered  vessel.  The  urine  is  collected  for 
24  hours. 

The  quantitative  determination  of  the  amount  of 
phthalein  passed  is  made  as  follows:  The  total  feces 
collected  are  put  in  a  wide  mouth  2  liter  bottle  diluted 
with  water  to  1  or  1.5  liters,  according  to  quantity, 
and  the  whole  put  in  a  shaking  machine  and  well  agi- 
tated for  from  5  to  20  minutes. 

One-tenth  of  the  total  amount  is  immediately  poured 


Tests  of  Liver  Function  61 

off  in  a  1-liter  flask.  To  this  is  added  5  c.c.  of  40% 
NaOH,  which  makes  the  mixture  a  dirty  red  color.  The 
flask  is  stoppered  and  thoroughly  shaken.  One  hun- 
dred (100)  c.c.  of  the  contents  of  this  flask  are  placed 
in  a  200  c.c.  flask,  to  which  is  added  5  c.c.  of  saturated 
basic  lead  acetate.  This  decolorizes  the  mixture  and 
throws  down  a  heavy  precipitate  which  leaves  a  color- 
less supernatant  liquid.  Five  (5)  c.c.  of  40%  solution 
of  NaOH  are  added,  which  produces  the  phthalein 
color.  More  hydroxide  solution  may  perhaps  be  needed 
to  bring  out  the  full  color,  but  excess  should  not  be 
used.  The  contents  of  the  flask  are  then  made  up  to 
200  c.c.,  shaken,  and  the  solution  allowed  to  stand  five 
minutes.  The  supernatant  fluid  is  clear  and  some  can 
be  poured  off  for  colorimetric  examination.  The  read- 
ing is  made  in  a  colorimeter  similar  to  the  one  used  in 
testing  kidney  permeability  with  phenolsulphonphtha- 
lein.  The  comparison  solution  is  made  by  taking  .4 
c.c.  of  the  original  solution  used  for  injection  and 
diluting  it  up  to  1  liter  plus  sufficient  NaOH  to  make 
the  deepest  color.  The  per  cent,  of  dye  eliminated  can 
be  read  off  on  the  instrument. 

If  the  reading  is  low  be  sure  that  the  maximum  color 
has  been  developed  by  adding  a  little  NaOH  again  to 
the  200  c.c.  dilution  above  mentioned.  NaOH  must  be 
carefully  added  because  excess  will  tend  to  render  solu- 
tions yellowish  red  instead  of  pure  purple  red. 

In  case  the  quality  of  color  is  unsatisfactory  the 
authors  of  the  test  recommend  the  following  procedure : 
After  the  addition  of  about  10  c.c.  of  40%  NaOH  dilute 
the  feces  mixture  up  to  1  liter.  Take  one-tenth  of  this 
and  add  5  c.c.  of  sodium  hydroxide  and  water  up  to  a 
liter.  One  hundred  c.c.  of  this  is  put  in  a  200  c.c.  flask 
and  to  it  is  added  5-10  c.c.  or  more  of  the  following 
solution : 


62      Manual  of  Vital  Function  Testing  Methods 

CaCl2    90  gms. 

Cone.  NH4OH 10  c.c. 

Water    50  c.c. 

This  brings  out  a  good  quality  of  color.  Dilute  up  to 
200  c.c.  and  allow  to  stand  covered  for  some  hours,  per- 
haps even  24.  The  supernatant  liquid  is  then  tested 
in  the  colorimeter  with  the  standard  solution  as  above. 
The  lower  limit  of  normal  output  is  20%. 

A  year's  experience  with  the  phenoltetrachlorphtha- 
lein  test  of  liver  function  has  prompted  a  recent  com- 
munication from  Chesney,  Marshall,  and  Rowntree 
(Jour.  Amer.  Med.  Assn.,  1914,  LXIII,  p.  1533)  in 
which  these  authors  conclude  that  outspoken  changes  in 
the  liver  can,  in  most  cases,  be  demonstrated  by  the  test. 
It  was  found  positive  in  advanced  cirrhosis,  in  passive 
congestion  (cardiac  liver)  and  in  cancer  and  syphilis 
involving  the  liver. 

These  authors  recommend  the  association  with  the 
phthalein  test,  of  estimation  of  nitrogen  partition  in 
the  blood  and  urine,  and  fibrinogen  estimation  in  the 
blood  serum. 

They  make  the  important  general  observation  that 
the  information  to  be  derived  from  tests  of  the  liver 
function  does  not  compare  in  reliability  with  that  ap- 
plied to  the  kidney.  Similar  views  have  likewise  been 
expressed  by  other  writers.  The  reason  would  appear 
to  be  plain.  We  do  not  as  yet  understand  the  functions 
of  the  liver  regarded  as  a  unit  or  dissociatively  as  we 
do  those  of  the  kidney.  The  symptomatology  of  hepatic 
insufficiency  is  not  understood  to  an  equal  extent  with 
that  of  the  kidney.  However  this  may  be,  sufficient 
progress  has  been  made  to  afford  ample  congratulations 
for  the  work  of  the  past  and  an  optimistic  outlook  for 


Tests  of  Liver  Fwnction  63 

future  developments. 

Krumbhar  43  has  recently  stated  as  a  result  of  his 
researches  and  investigations  that  the  phenoltetrachlor- 
phthalein  test  of  Rowntree,  Horwitz,  and  Bloomfield 
promises  a  greater  value  than  all  other  tests  so  far 
devised  for  estimating  the  functional  capacity  of  the 
liver. 

43  N.  Y.  Med.  Jour.,  1914,  c.  719. 


CHAPTER  II 
TESTS  OF  KIDNEY  FUNCTION 

GENERAL   CONSIDERATIONS 

Historical. — In  1830  Hahn  noticed  after  ingestion 
of  turpentine  in  gouty  persons  that  the  substance  failed 
to  render  the  urine  odorous  as  it  was  known  to  do  in 
healthy  persons.  In  1837  Rayer  noticed  the  same 
thing  with  regard  to  asparagus. 

Clinicians  for  a  long  time  have  known  that  many 
persons  with  nephritis  can  not  take  mercury,  salicylates, 
iodides,  bromides  and  various  other  drugs  without  rap- 
idly showing  signs  of  intolerance.  Todd  wrote  upon 
this  subject  in  1857  and  Roberts  in  1865.  Duckworth 
and  Bouchard  in  1873  showed  experimentally  that 
many  drugs  which  normally  pass  quite  readily  through 
the  kidney,  fail  to  do  so  in  nephritis. 

The  first  practical  application  of  these  facts  was 
made  by  Achard  and  Castaigne,  who  introduced  methyl- 
ene  blue  in  1897  as  a  direct  test  of  the  functional 
capacity  of  the  kidneys. 

Physiological. — As  well  expressed  by  Blum  the  fun- 
damental function  of  the  kidney  is  its  osmoregula- 
tory  power;  its  power  to  constantly  maintain  at  an 
unvarying  point  the  molecular  concentration  of  the 
blood.  This  it  does  by  removing  a  series  of  substances 
whose  accumulation  in  the  organism  would  eventually 

64 


Tests  of  Kidney  Function  65 

produce  serious  and  even  fatal  consequences.  These 
substances  are  removed  in  the  urine. 

Two  general  theories  of  urinary  secretion  have 
existed,  side  by  side,  for  several  decades.  They  are 
known  eponymically  by  their  originators  and  although 
they  have  been  added  to  or  subtracted  from  in  details 
by  a  host  of  subsequent  workers  they  yet  stand  as  op- 
posing schools  of  physiological  interpretation.  These 
schools  are  known  as  that  of  Ludwig  on  the  one  hand 
and  that  of  Bowman-Heidenhain  on  the  other. 

According  to  Ludwig,  the  elimination  of  urine  is  a 
simple  process  of  physical  filtration  and  diffusion.  The 
anatomical  structure  of  the  glomcrulus  and  the  physio- 
logical conditions  existing  therein,  appearing  to  favor 
the  idea  of  filtration,  Ludwig  believed  that  water  passes 
through  the  epithelium  of  the  capillary  wall  and  the 
glomerular  epithelium  as  through  a  filter,  carrying  with 
it  sodium  chloride  and  other  inorganic  salts  and  urea, 
and  that  the  diluted  urine  in  its  passage  through  the 
uriniferous  tubules  becomes  concentrated  through  loss 
of  water  by  diffusion  into  the  more  concentrated  blood 
and  lymph. 

According  to  the  other  theory,  that  of  Bowman- 
Heidenhain,  the  elimination  of  urine  is  fundamentally 
a  secretory  act  and  not  fundamentally  a  physical  act. 
It  assumes  that  the  glomerulus  secretes  water  and  inor- 
ganic salts  while  the  epithelial  cells  of  the  uriniferous 
tubules  secrete  urea  and  the  other  specific  constituents 
of  the  urine. 

We  shall  not  attempt  here  either  a  historical  or  phys- 
iological review  of  these  theories.  It  may  be  said  that 
the  majority  of  physiologists  adhere  to  the  more  con- 
servative and  vitulistic  hypothesis  of  Bowman-Heiden- 
hain. The  grounds  for  this  belief,  and,  indeed,  all  of 
the  facts  bearing  upon  both  sides  of  this  now  classical 


66      Manual  of  Vital  Function  Testing  Methods 

controversy,  are  properly  to  be  found  in  any  modern 
text  book  of  physiology.1 

It  is  pretty  generally  agreed  that  whether  by  filtra- 
tion or  secretion,  water  leaves  the  kidney  through  the 
glomerulus.  Beyond  this  generally  accepted  fact  there 
is  so  little  unanimity  of  opinion  as  to  the  exact  place 
where  sodium  chloride  urea  and  the  other  solid  constitu- 
ents of  the  urine  are  eliminated,  that  it  is  impossible  to 
make  any  categorical  statement  with  reference  thereto. 
Many  attempts  have  been  made  to  divide  up  the  total 
kidney  function  into  categories  or  topical  functions  and 
to  locate  these  functions  anatomically  in  parts  of  the 
glomerulo-tubal  structure.  But  it  cannot  be  pretended 
at  the  present  time  that  any  such  differentiation  has 
been  proven,  certainly  not  to  such  an  extent  as  to 
justify  deductions  of  great  practical  importance.  This 
question  will,  however,  be  more  fully  elaborated  later. 

The  composition  of  the  urine  is  far  from  simple.  Its 
chief  constituents,  apparently,  are  water,  sodium  chlo- 
ride and  urea.  But  besides  these  substances,  urine  con- 
tains purine  bodies  (uric  acid,  xanthin,  hypoxanthin), 
creatinin,  oxalates,  glycuronates,  phosphates,  sul- 
phates, various  oxy-nitrogenous  and  fatty  acids,  and 
the  pigments  urochrome  and  urobilin. 

Nearly  all  of  the  nitrogen  excreted  from  the  body  is 
supposed  to  pass  through  the  kidney.  The  total  amount 
of  nitrogen  eliminated  in  the  urine  in  24  hours  is  conse- 
quently regarded  as  the  most  important  index  of  proteid 
metabolism.  The  actual  estimate  of  total  urinary  nitro- 
gen is  usually  done  by  the  method  of  Kjeldahl  (described 
under  Liver  Tests,  q.  r.). 

The  total  weight  of  nitrogen  in  the  urine  multiplied 
by  6.25  gives  the  amount  of  protein  broken  down  in 
the  body,  since  nitrogen  forms  16%  of  the  weight  of 

1  See  Howell,  Halliburton,  etc. 


Tests  of  Kidney  Function  67 

the  protein  molecule.  The  total  amount  of  nitrogen 
eliminated  in  24  hours  by  a  normal  adult  is  between 
14  and  18  grams,  which  corresponds  to  88-117  grams 
of  protein. 

The  total  nitrogen  eliminated  in  the  urine  is  divided 
as  follows:  1.  Urea  nitrogen;  this  averages  87.5%  of 
the  total.  2.  Ammonia  nitrogen;  this  averages  4.3% 
of  the  total.  3.  Creatinin  nitrogen,  3.6%.  4.  Purin 
nitrogen,  variable. 

Urea  occurs  in  the  urine  as  its  chief  nitrogenous 
constituent  (about  2%  ).  Since  a  normal  adult  secretes 
1500  to  1700  c.c.  of  urine  in  24  hours  the  amount  of 
urea  eliminated  will  vary  from  30  to  34  grams.  Urea, 
of  course,  is  not  manufactured  by  the  kidneys,  but  is 
merely  eliminated  by  them.  Urea  is  a  normal  con- 
stituent of  blood  existing  in  that  fluid  in  quantities 
varying  from  .035  to  .153%.  If  the  kidneys  are  re- 
moved or  become  impassible  to  urea  this  substance 
accumulates  in  the  blood. 

Sodium  chloride  is  the  chief  inorganic  constituent  of 
urine,  amounting  to  about  15  grams  per  day  in  a  nor- 
mal adult. 

Under  pathological  conditions  a  variety  of  sub- 
stances organic  and  inorganic  may  appear  in  the  urine, 
whose  search  and  identification  is  a  part  of  the  routine 
analysis  conducted  for  clinical  purposes. 

A  consideration  of  these  substances  belongs,  of 
course,  to  the  domain  of  general  clinical  pathology. 
The  question  of  how  far  an  ordinary  urinary  examina- 
tion can  serve  to  reveal  the  functional  capacity  of  the 
kidney  will  be  taken  up  presently. 

The  kidney  functionates  normally  at  a  point  below 
its  maximum  capacity,  retaining  unused  a  certain 
amount  of  functional  energy  which  constitutes  its  re- 
serve. When  this  reserve  becomes  exhausted  the  func- 


68      Manual  of  Vital  Function  Testing  Methods 

tional  capacity  of  the  organ  will  be  irremediably  dam- 
aged unless  it  can  recuperate.  When  uremia  or  edema 
have  appeared  the  amount  of  functional  incapacity  of 
the  kidney  has  become  considerable.  No  special  test  of 
function  is  required  to  discover  it,  perhaps,  but  even 
under  such  conditions,  it  may  be  extremely  useful  to 
determine  just  how  far,  in  any  given  case,  the  deprecia- 
tion of  functional  integrity  has  gone. 

Classification. — There  are  various  general  plans  by 
which  the  functional  state  of  the  kidney  may  be  in- 
vestigated. 

In  the  first  place  we  may  determine  how  far  the  kid- 
ney is  able  to  eliminate  increased  amounts  of  its  normal 
constituents,  such  as  water,  salt  and  urea. 

In  the  second  place  we  may  select  substances  foreign 
to  the  organism,  but  which  are  eliminated  by  the  kid- 
ney, and  determine  the  rate  and  quantity  of  their  excre- 
tion. Iodide  of  potassium,  lactose,  phenolsulphon- 
phthalein,  phloridzin  are  examples  of  such  substances. 

Thirdly,  the  study  of  the  blood  will  constitute  an- 
other avenue  of  approach  to  the  problem  of  estimating 
the  function  of  the  kidney,  because  one  important  result 
of  renal  insufficiency  will  be  the  accumulation  of  sub- 
stances in  the  blood  which  should  be  eliminated  in  the 
urine.  Among  methods  of  this  type  may  be  mentioned 
partitive  estimations  of  nitrogen  in  the  blood,  particu- 
larly incoagulable  nitrogen.  Such  examinations  will 
often  disclose  an  abnormal  degree  of  accumulation  or 
retention  of  such  products  in  the  blood  if  a  condition 
of  renal  impermeability  or  insufficiency  exists. 

Thus  it  will  be  seen  that  all  tests  for  kidney  function 
are  based  upon  the  broad  principle  that  any  deprecia- 
tion of  renal  activity  will  be  reflected  in  the  urine  on  the 
one  hand  and  the  blood  upon  the  other.  The  urine  will 
contain  less  of  its  normal  constituents  than  normally 


Tests  of  Kidney  Function  69 

and  less  of  any  substance  artificially  eliminated  by  the 
kidney,  while  the  blood  will  show  the  effects  of  renal 
inadequacy  by  disclosing  an  accumulation  in  the  plasma 
of  substances  which  are  normally  excreted  continuously 
in  adequate  amounts. 

All  tests  for  renal  function  so  far  devised  may  be 
satisfactorily  divided  into  the  three  following  cate- 
gories : 

1.  The  urine  as  an  index  of  renal  function — (a) 
Urinalysis,  (b)  Physical  and  Biological  characteristics. 
2.  The  Blood  as  an  index  of  renal  function.  3.  Elimi- 
nation of  foreign  substances  by  the  kidney  as  an  index 
of  renal  function. 

In  the  following  synopsis,  we  may  see  how  the  various 
tests  which  have  come  to  be  used  can  be  distributed 
among  the  three  classes : 

I.  Urinalysis  as  an  index  of  renal  function. 

A.  Urinalysis. 

1.  Estimation  of  water :  experimental  polyuria. 

2.  Estimation  of  sodium  chloride :  experimental 

chloruria. 

3.  Estimation  of  urinary  nitrogen ;  urea,  etc. 

4.  Estimation  of  urinary  coloring  matter. 

5.  Estimation  of  urinary  diastase. 

B.  Physical  and  biological  characteristics. 

1.  Cryoscopy  of  the  urine. 

2.  Electrical  conductivity  of  the  urine. 

3.  Estimation  of  urinary  toxicity. 

IT.   Studies  of  the  blood  as  indices  of  renal  function. 

1.  Estimation  of  blood  urea  and  of  incoagu- 

lable (residual)  nitrogen  in  blood. 

2.  Estimation  of  coagulation  time. 

3.  Cryoscopy  of  the  blood. 


70      Manual  of  Vital  Function  Testing  Methods 

III.   Studies  of  elimination  of  foreign  substances  by  the 
kidney  as  criteria  of  function. 

A.  Miscellaneous. 

1.  Potassium  Iodide. 

2.  Phloridzin. 

3.  Hippuric  Acid. 

4.  Lactose. 

B.  Dyes  or  colors:  experimental  urinary  chromos- 

copy. 

1.  Methylene  blue. 

2.  Indico  carmine. 

3.  Phenolsulphonephthalein. 


I.       THE    STUDY    OF    UUINALYSIS    AS    AN    INDEX    OP    RENAL 
FUNCTION 

A .   Urinalysis 

The  urine  represents,  as  it  were,  the  concrete  results, 
almost  the  total  results  of  renal  activity.  Inasmuch 
as  the  entire  urinary  output  of  the  kidney  for  any  given 
period  of  time  may  be  readily  collected  it  would  seem 
natural  to  assume  that  a  chemical  analysis  would  throw 
all  the  light  that  is  necessary  upon  the  problem  of  renal 
function ;  but  as  a  matter  of  fact,  while  it  is  true  that 
chemical  analysis  of  the  urine  provides  an  adequate 
insight  into  the  amount  of  salts,  of  water  and  of  urea 
secreted  by  the  kidney,  it  is  not  true  that  urinalyses 
are  sufficient  to  determine  the  functional  capacity  of 
the  organ.  Gross  anatomical  and  physiological  disturb- 
ances are  often  thus  discovered  and  extremely  important 
information  is  thus  derived  concerning  the  diagnosis  of 
diseases  of  the  kidney  and  urinary  organs. 

But  this  is  a  very  different  proposition  from  deter- 


Tests  of  Kidney  Function  71 

mining  thereby  the  functional  capacity  or  incapacity  of 
the  kidney,  in  the  absence  of  evidence  of  gross  organic 
lesion.  Even  under  apparently  normal  circumstances 
the  actual  amount  of  the  different  urinary  constituents 
excreted  may  vary  considerably.  For  example  the 
chlorides  may  be  eliminated  in  excess  and  nitrogen  re- 
tained or  vice  versa.  But  such  variations  are  not  neces- 
sarily dependent  on  anatomical  lesions  of  the  kidney 
or  even  upon  any  disturbance  of  renal  permeability. 

If,  in  a  given  24-hour  specimen  of  urine,  the  figures 
representing  the  elimination  of  the  different  important 
constituents  depart  from  the  usual  normal,  we  cannot 
draw  any  absolute  conclusions  from  this  fact  alone  as 
to  whether  the  functional  capacity  of  the  kidney  is 
below  or  above  normal.  One  reason  for  this  is  that  the 
chemical  constitution  of  the  urine  is  not  dependent 
alone  upon  kidney  functional  power  but  it  is  influenced 
by  a  large  number  of  extremely  important  extrarenal 
factors,  among  which  may  be  mentioned  the  intake  of 
food  and  fluids,  the  condition  of  the  nervous  system  and 
other  organs,  etc. 

It  is  a  well-known  fact  that  before  any  important 
conclusions  as  to  nitrogen  metabolism  can  be  drawn 
from  the  chemical  constitution  of  the  urine,  these  factors 
must  be  taken  into  consideration,  and  if  they  are  ade- 
quately considered  the  task  becomes  complicated  by 
many  necessary  experimental  refinements.  The  whole 
question  of  body  metabolism  must  be  taken  up.  The 
intake  and  output  in  every  direction  must  be  measured. 
But  even  after  this  is  done  and  it  is  demonstrated  from 
urinalysis  that  there  is  a  deficit  in  nitrogen  excretion, 
the  kidney  function  may  be  perfect  and  the  nitrogen 
simply  retained  in  the  tissues. 

Variations  in  nitrogen  elimination  occur  under  so 
many  different  conditions  that  interpretation  is  often 


72      Manual  of  Vital  Function  Testing  Methods 

difficult  or  impossible.  The  same  may  be  said  with 
regard  to  the  output  of  other  constituents  of  the  urine. 

Concerning  the  application  of  urinalysis  to  the  inter- 
pretation of  kidney  function  it  may  be  said  that  if  the 
figures  are  all  consistently  and  invariably  normal,  the 
kidney  function  is  apt  to  be  good;  and  if  there  is  a 
persistent  and  considerable  departure  from  normal  the 
kidney  function  may  be  deficient. 

But  in  order  to  be  of  real  value,  the  tests,  particularly 
those  regarding  the  nitrogen  excretion,  must  often  as- 
sume the  proportion  of  metabolism  experiments,  which 
makes  them  impractical  for  clinical  use. 

Fortunately  for  the  purposes  of  clinical  medicine  the 
physician  will  not  be  called  upon  to  consider  the  in- 
tricate problems  of  nitrogen  metabolism  in  his  investi- 
gations of  renal  function.  His  desire  will  be  to  know 
the  capacity  of  the  kidney  to  do  its  work  and  fortu- 
nately this  object  may  be  accomplished  without  recourse 
to  extremely  elaborate  and  technical  processes. 

We  are  justified  in  expecting  that  under  an  average 
regimen  the  kidneys  will  eliminate  somewhere  near  the 
average  amounts  of  the  urinary  constituents.  But 
knowing  how  many  and  how  variable  the  extrarcnal  fac- 
tors are  which  influence  the  absolute  quantities  of  uri- 
nary constituents  eliminated,  it  will  become  apparent 
that  the  results  of  a  urinalysis,  no  matter  how  complete, 
will  require  to  be  supplemented  by  other  and  better 
means  of  determining  the  functional  capacity  of  the 
kidney. 

1 .     Estimation  of  Urinary  Water  as  an  Index  of  Renal 
Function.  Experimental  Polyurla.  Albarran's  Method 

The  healthy  kidney  possesses  the  power  in  a  high 
degree  to  adapt  itself  to  those  tendencies,  such  as  addi- 
tion or  subtraction  of  water  to  or  from  the  circulating 


Tests  of  Kidney  Function  73 

blood,  which  would  tend  to  alter  the  molecular  concen- 
tration of  the  fluid.  It  quickly  re-establishes  both  mo- 
lecular and  water  equilibrium,  thus  maintaining  an 
equable  osmotic  tension  in  the  blood  and  lymph.  Super- 
fluous water  is,  normally,  quickly  eliminated  through 
the  glomerulus  and  reabsorption  in  the  canaliculus  is  in- 
hibited. When  the  supply  of  water  to  the  organism  is 
deficient,  the  resorptive  function  of  the  canaliculus  is 
raised  and  a  more  highly  concentrated  urine  is  elimi- 
nated. This  function  of  the  kidney  may  be  properly 
termed  its  diluting-concentrating  power. 

Since  water  secretion  is  a  function  of  the  glomerulus, 
the  diluting  power  of  the  kidney  is  a  glomerular  func- 
tion. The  functionally  weak  kidney  is  not  only  unable 
to  produce  a  highly  concentrated  urine  but  also  unable 
to  elaborate  a  much  diluted  one.  The  concentrating 
power  of  the  kidney  is  a  function  of  the  epithelium  of 
the  uriniferous  tubes  (canaliculus). 

The  diluting-concentrating  power  of  the  kidney  suf- 
fers in  diffuse  kidney  disease  in  proportion  to  the 
amount  of  parenchyma  involved.  In  parenchymatous 
nephritis  the  water  secreting  power  of  the  kidney  is 
lowered ;  in  contracted  kidney  it  is  more  or  less  retained. 

The  increased  urine  following  an  experimental  pro- 
vocative polyuria  test  differs  from  the  increased  secre- 
tion following  a  heavy  meal,  since  in  the  former  case  the 
freezing  point  (A),  molecular  concentration,  chloride, 
phosphate  and  urea  content  (specific  gravity)  are  all 
diminished,  while  in  the  latter  they  are  all  increased. 

With  respect  to  continuity  of  function  the  diseased 
organ  possesses  a  greater  constancy  and  invariability 
in  proportion  to  the  amount  of  disease.  The  normal 
kidney  function  tends  to  vary,  that  is,  to  adapt  itself  to 
the  constantly  changing  conditions  in  the  organism. 
The  diseased  organ  has  no  such  power. 


74      Manual  of  Vital  Function  Testing  Methods 

The  healthy  kidney  always  functions  below  its  maxi- 
mum strength;  always  possesses,  in  other  words,  a  cer- 
tain reserve  power  which  can  be  used  under  extraor- 
dinary circumstances,  such  as  great  increase  in  water 
and  solid  molecular  intake.  The  insufficient  kidney  is 
unable  to  meet  these  requisitions  for  added  energy,  and 
responds  but  little  if  at  all  to  extra  stimulation.  It 
has  lost  its  reserve. 

As  a  corollary  to  the  above  it  may  be  added  that  if 
one  kidney  is  diseased  and  the  excretion  from  the  two 
organs  be  compared,  the  facts  as  above  stated  will 
apply.  The  affected  kidney  is  less  able  to  respond  to 
adaptation  requirements  than  the  normal  and  the  degree 
of  its  failure  to  do  so  may  properly  be  taken  as  the 
measure  of  its  incapacity. 

For  these  reasons  polyuria  tests  may  be  employed 
with  the  view  of  conducting  examinations  upon  the  total 
excretion  or  whenever  necessary  upon  the  excretion  ob- 
tained by  ureteral  catheterization  from  each  organ 
separately. 

The  Water  Tests. — The  provocative  polyuria  tests 
are  usually  carried  out  with  water.  The  tests  should 
be  applied  in  the  morning  on  an  empty  stomach.  The 
morning  urine  prior  to  the  test  should  be  measured  and 
examined  for  quantity  and  specific  gravity,  total  sodi- 
um chloride  and  urea  elimination  and  perhaps  cryo- 
scopically.  The  patient  is  then  given  500-700  c.c.  of 
mineral  water  or  ordinary  water.  The  urine  should  be 
collected  every  half  hour  by  voiding  or  catheter  if  the 
total  amount  is  to  be  examined  (general  renal  function) 
or  by  ureteral  catheterization  if  the  separate  kidney 
functions  arc  to  be  compared. 

Under  normal  circumstances  the  polyuria  appears 
within  the  first  half  hour,  reaching  its  maximum  at  this 
time,  and  quickly  sinking.  The  content  of  solids  sinks. 


Tests  of  Kidney  Function  75 

The  freezing  point  (A)  diminishes. 

If  the  functional  power  of  the  organ  is  below  normal, 
the  polyuria  is  delayed  or  does  not  occur  and  the 
amount  of  variation  from  the  normal  may  be  taken  as 
a  fair  measure  of  the  incapacity. 

Straus-Grunwald  Method. — The  patient  takes  noth- 
ing after  7  P.  M.  into  the  stomach.  At  6:30  A.  M.  the 
following  morning  a  pint  of  water  is  ingested.  The 
night  urine  is  collected;  also  that  voided  at  7,  8,  9,  10, 
and  11  A.  M.  The  amount  and  specific  gravity  of  each 
portion  are  recorded.  The  patient  remains  in  a  reclin- 
ing position  during  the  time  of  the  test. 

In  normal  cases  an  amount  of  urine  is  passed  in  the 
first  3  hours  equal  to  that  which  was  drank.  That  is 
by  10  A.  M.  at  least  a  pint  is  voided.  At  8  A.  M.  the 
sp.  gr.  is  lowest.  Variations  in  the  amount  voided,  time 
required,  and  specific  gravity  will  indicate  abnormal 
renal  function. 

The  Diuretic  Tests  {pharmacological}. — Caffein, 
diuretin,  theophyllin  (theocin),  euphyllin  and  other 
diuretic  substances  have  been  employed,  but  none  of 
these  drugs  has  been  found  to  possess  much  advantage 
over  the  simple  water  test.  The  diuretic  drugs  appear 
to  increase  the  solid  constituents  of  the  urine  as  well  as 
the  fluids.  Blum,  who  introduced  euphyllin,  does  not 
recommend  it  because  he  has  found  a  fall  of  blood  pres- 
sure follow  its  hypodermic  or  intravenous  administra- 
tion. 

None  of  these  tests  have  acquired  a  sufficient  promi- 
nence to  justify  their  description. 

While  the  so-called  water  or  polyuria  tests  have 
proven  of  some  value  in  estimating  relative  function  in 
the  separate  kidney  secretions,  it  is  generally  agreed 


76      Manual  of  Vital  Function  Testing  Methods 

that  they  arc  of  much  less  importance  in  estimating 
total  kidney  function. 

The  absolute  quantity  of  urine  voided  varies  very 
greatly  under  normal  and  abnormal  circumstances. 
According  to  Rowntree  and  Fitz  there  is  no  constant 
relation  between  the  existence  of  polyuria  or  oliguria 
and  the  condition  of  kidney  function  as  shown  by  other 
well-recognized  tests.  This  applies  to  nephritic  and 
cardiac  cases  and  to  combinations  of  these. 

The  specific  gravity  of  the  urine  in  advanced  nephri- 
tis according  to  these  authors  is  usually  low. 

2.     Estimation   of  Sodium   Chloride   as   an  Index  of 
Renal  Function 

Ten  to  fifteen  grams  of  sodium  chloride  are  excreted 
by  a  normal  adult  in  24  hours.  The  rapidity  with 
which  the  kidneys  can  excrete  a  considerable  amount  of 
sodium  chloride  has  been  suggested  and  employed  as  a 
test  for  renal  function. 

With  regard  to  the  method  of  so-called  forced  elim- 
ination of  sodium  chloride,  it  must  be  freely  granted 
that  the  problem  is  a  very  difficult  and  complicated  one. 

If  diminished  secretion  of  sodium  chloride  always 
indicated  renal  impermeability  the  problem  would  be 
solved,  but  this  is  by  no  means  the  case.  The  tissue 
fluids  themselves,  everywhere  in  the  body  perhaps,  have 
varying  affinities  for  sodium  chloride  and  a  diminution 
of  chloride  elimination  may  not  signify  a  diminished 
permeability  of  the  kidney  for  salt  but  only  an  increased 
retention  of  salt  in  the  body. 

Nevertheless  there  is,  under  normal  circumstances,  a 
very  close  relation  between  the  intake  of  sodium  chloride 
in  the  food  and  its  elimination  by  the  kidneys.  So  that 
if  an  individual  is  placed  for  a  period  of  time  upon  a 


Tests  of  Kidney  Function  77 

regimen  containing  a  low  percentage  of  salt,  the  excre- 
tion of  that  substance  will  become  reduced  to  a  lower 
equilibrium.  If  now  the  quantity  of  sodium  chloride 
ingested  be  suddenly  increased  there  will  be  an  immediate 
and  proportionate  increase  in  the  amount  secreted. 

If  there  is  no  increase,  it  will  be  difficult  to  determine 
whether  there  is  chloride  retention  or  defective  excre- 
tion so  that  the  chloride  test  is  seldom  used  alone  as  a 
measure  of  renal  function. 

The  exact  situation  in  the  glomerulo-tubular  mechan- 
ism where  sodium  chloride  is  excreted,  is  not  known 
with  certainty.  .  According  to  the  rather  recent  investi- 
gations of  Schlaycr  and  Takayasu  and  Von  Monakow, 
sodium  chloride  is  excreted  by  the  tubular  epithelium, 
or  more  exactly  the  excretion  of  salt  following  its  ad- 
ministration in  amounts  in  excess  of  the  usual  daily 
intake  is  accomplished  by  the  tubules. 

When  large  amounts  of  salt  are  ingested  the  excre- 
tion, according  to  Schlayer,  takes  place  in  one  of  two 
ways,  depending  upon  the  amount  of  water  simultane- 
ously absorbed.  If  the  salt  is  given  without  extra  water 
it  is  almost  entirely  secreted  within  24?  hours  without 
diuresis,  by  an  increased  concentration  of  the  urine.  If, 
however,  it  is  given  with  an  excess  of  water  it  is  secreted 
partially  through  increased  concentration  and  partially 
through  diuresis. 

If  the  vascular  structure  of  the  kidney  is  injured, 
the  ingestion  of  salt  may  be  followed  by  marked  diure- 
sis, the  salt  all  escaping  in  the  urine  in  21  hours  with- 
out the  percentage  content  being  increased.  The  spe- 
cific gravity  may  be  low  and  tends  to  remain  at  a  fixed 
point.  To  tin's  combination  of  phenomena,  Schlayer 
gave  the  name  vascular  hyposthenuria,  and,  according 
to  his  idea,  the  inability  of  the  kidney  to  eliminate  a 
urine  concentrated  in  salt  is  not  due  to  tubular  defect 


78      Manual  of  Vital  Function  Testing  Methods 

but  to  a  hypersensitive  condition  of  the  blood  vessels 
which  allows  the  secretion  of  the  salt  in  relatively  large 
amounts  of  water;  in  other  words,  the  sensitive  vessels 
respond  to  the  salt  administration  by  the  diuresis. 
When  the  vascular  injury  is  more  marked  the  vessels  do 
not  so  react  but  respond  with  oliguria. 

In  severe  tubular  epithelial  disease,  however,  the 
quantity  of  salt  eliminated  is  not  raised  by  the  adminis- 
tration of  salt.  Here  a  urine  of  fixed  low  specific  grav- 
ity of  moderate  quantity  is  obtained.  The  salt  is  re- 
tained. There  is,  according  to  Schlayer,  a  tubular 
hyposthenuria. 

These  interesting  findings  reported  by  Schlayer  and 
his  school  have  not  been  completely  corroborated  and 
it  does  not  appear  to  be  agreed  at  the  present  time  that 
any  absolute  distinction  between  vascular  and  tubular 
hyposthenuria  can  be  founded  upon  the  response  of  the 
kidney  to  tests  with  sodium  chloride. 

In  fact  the  number  of  extrarenal  factors  concerned 
in  the  salt  output  are  so  many  and  so  illy  understood 
that  the  salt  test  alone  is  considered  of  no  value.  But 
when  considered  in  conjunction  with  other  functional 
tests  and  with  clinical  findings  in  cardiac  and  renal 
cases  it  may  be  of  some  diagnostic  and  prognostic 
value. 

In  advanced  nephritis  there  seems  no  doubt  that 
salt  elimination  is  lessened  to  a  certain  extent  but 
if  the  patient  has  been  on  a  salt-poor  diet  for  a  time 
previous  to  the  test,  the  tissues  will  retain  salt  when 
administered  regardless  of  the  cardiorenal  condition. 

(Edema  is  the  symptom  in  chronic  nephritis  which 
is  usually  associated  with  the  idea  of  chloride  reten- 
tion. It  is  not  positively  known  just  what  factors  are 
concerned  in  this,  or  whether  they  are  chiefly  renal  or 
extrarenal. 


Tests  of  Kidney  Function  79 

It  is  on  the  basis  of  the  supposed  connection  be- 
tween oedema  and  chloride  retention  that  the  now  well- 
known  method  of  salt  reduction  in  the  treatment  of 
oedema  in  Bright's  disease  was  introduced. 

Technic  of  Sodium  Chloride  Test.  Test  of  Alimen- 
tary Chloruria.—  The  patient  is  placed  on  a  diet  con- 
taining about  5  gms.  of  salt  per  day.  After  several 
days  or  when  the  salt  output  is  approximately  con- 
stant, 5-10  gms.  of  sodium  chloride  are  given,  dis- 
solved in  125  c.c.  of  water.  The  quantity  is  taken  in 
three  portions  during  the  day.  This  is  kept  up  for 
four  consecutive  days.  The  daily  output  of  chloride 
is  determined  by  the  method  described  below.  If  the 
patient  is  kept  on  a  salt-poor  diet,  say  2.5  gms.  daily 
for  some  time  previous  to  the  test,  it  will  be  found  that 
excretion  will  always  be  lessened  from  a  normal  ten- 
dency of  the  tissues  to  retain  chlorides.  For  this 
reason  the  best  method  consists  in  merely  establishing 
chloride  equilibrium  before  the  test  is  started. 

Estimation  of  Sodium  Chloride  in  the  Urine. — The 
principle  of  the  test  is  that  chlorides  are  precipitated 
by  solutions  of  nitrate  of  silver.  Volhardt's  method 
with  its  various  modifications  is  regarded  as  the  most 
accurate  quantitative  method  of  chloride  estimation, 
and  is  used  when  the  exact  amount  must  be  known  as 
in  metabolic  experiments. 

For  all  practical  purposes  Mohr's  method  will  suf- 
fice.2 The  strength  of  silver  solution  used  in  the  test 
is  such  that  1  c.c.  corresponds  to  .01  gm.  of  sodium 
chloride.  Such  a  solution  contains  29.06  gms.  of  pure 
fused  silver  nitrate  to  the  liter.  The  technic  of  the 
estimation  is  as  follows : 

2  The  Lutke-Martius  method  is  often  recommended,  see  Sahli's 
Diagnostic  Methods,  1911,  p.  455. 


80      Manual  of  Vital  Function  Testing  Methods 

10  c.c.  of  urine  previously  freed  from  albumen  are 
put  in  an  Erlenmeyer  flask  or  porcelain  capsule  and 
100  c.c.  of  water  added  and  several  drops  of  potassium 
chromate  solution,  enough  to  produce  a  distinct  yel- 
low color. 

The  standard  silver  solution  is  added  from  a  burette, 
stirring  until  the  reddish  orange  color  which  appears 
first  where  the  drop  falls  is  distributed.  The  first 
permanent  orange  color  trace  is  the  end  of  the  reac- 
tion. The  operation  should  be  repeated  if  necessary, 
to  make  certain  of  results.  The  number  of  c.c.  used 
multiplied  by  .01  gives  the  amount  of  sodium  chloride. 
The  results  are  a  little  high  but  near  enough  for  prac- 
tical purposes.  A  rough  estimate  of  the  amount  of 
chloride  in  the  urine  may  be  made  as  follows :  To  a 
test  tube  of  clear  urine  non-albuminous,  add  10  drops 
of  pure  HNO3  and  one  drop  of  AgNO3  (1  to  8).  If 
chlorides  are  normal  or  increased,  the  precipitate  is 
a  compact  ball  which  sinks  to  the  bottom.  If  dimin- 
ished, the  ball  is  less  compact.  If  much  diminished, 
only  a  cloud  is  produced  without  solid  flakes.  This 
last  represents  a  chloride  content  of  \%  or  less. 

3.     Estimation  of  Urinary  Nitrogen  as  an  Index  of 
Hcnal  Function 

When  functional  tests  of  the  liver  were  being  dis- 
cussed (z'.s.)  considerable  emphasis  was  laid  upon  in- 
terpreting ureagenetic  disturbance  of  that  organ  by 
taking  into  consideration  the  different  phases  of  nitro- 
gen metabolism  which  arc  so  closely  connected  with 
liver  activity.  It  was  then  shown  that  a  knowledge 
of  total  nitrogen  elimination  in  the  urine  and  particu- 
larly of  the  different  forms  in  which  the  nitrogen  is 
eliminated,  will  shed  light  upon  the  condition  of  liver 


Tests  of  Kidney  Function  '81 

functional  power. 

The  reasons  for  these  assumptions  were  given  in 
their  proper  place,  but  it  may  be  serviceable  to  refer 
again  to  the  fact  that  the  liver  is  regarded  as  a  very 
important  locus  for  the  synthesis  of  urea  in  the  body. 
For  this  reason  it  is  quite  reasonable  to  suppose  that 
functional  depreciation  of  the  liver  cells  would  be  re- 
flected to  an  appreciable  extent  by  the  quantitative 
relative  variations  of  the  nitrogen  constituents  of  the 
urine. 

When  now  we  come  to  the  significance  of  nitrogen 
elimination  in  the  urine  to  disorders  of  kidney  activity, 
it  will  be  necessary  to  remember  that  the  kidney  has 
nothing  to  do  whatever  in  a  specific  way  with  the  nitro- 
gen metabolism.  Its  only  function  is  to  excrete  the 
nitrogenous  waste  products  which  are  brought  to  it 
by  the  blood.  That  urea  is  not  manufactured  by  the 
kidney  is  proved  by  the  fact  that  if  blood  is  perfused 
thro  an  isolated  kidney,  no  urea  is  formed  even  tho 
substances  such  as  ammonium  carbonate,  from  which 
urea  is  readily  produced,  are  added  to  the  blood.  It 
is  well  known  that  if  the  kidneys  are  removed  in  ani- 
mals or  their  function  paralyzed,  urea  will  continue  to 
accumulate  in  the  blood  as  long  as  the  animal  sur- 
vives. 

No  physiological  fact  is  bettor  known  than  that 
the  relative  amount  of  urea  nitrogen  in  the  urine  varies 
directly  with  the  amount  of  protein  food  ingested. 
Other  nitrogenous  constituents  of  the  urine,  the  purin 
bodies  and  creatinin,  are  unaffected  by  the  intake.  This 
suggested  to  Folin  that  most  of  the  urea  in  the  urine 
may  come  directly  from  food  proteins  which,  having 
been  hydrolyzed  in  the  intestine  into  amino  acids,  are 
absorbed  and  further  hydrolyzed  and  oxidized  and 
the  nitrogen  constituent  immediately  eliminated  as 


82     Manual  of  Vital  Function  Testing  Methods 

urea.  The  liver  has  most  to  do  with  this  process  though 
the  urea  forming  function  of  this  organ  is  known  to 
be  shared  by  some  other  tissues  since  even  after  the 
removal  of  the  liver  some  urea  is  formed. 

These  physiological  principles  being  agreed  upon, 
it  is  easy  to  appreciate  that  the  question  of  the  estima- 
tion of  urinary  nitrogen  as  an  index  of  renal  function 
will  be  practically  confined  to  the  estimation  of  the 
amount  of  urea  eliminated  under  normal  circumstances, 
the  patient  being  on  a  fixed  diet,  with  an  estimation 
of  the  power  of  the  kidney  to  eliminate  more  urea  when 
the  proteid  intake  is  increased,  or  when  urea  itself  is 
ingested.  The  question  of  nitrogen  accumulation  in 
the  blood  as  an  index  of  renal  insufficiency  will  be  dis- 
cussed below,  when  the  study  of  the  blood  as  an  index 
of  renal  function  is  considered.  It  may  be  admitted 
here  that  the  study  of  the  partition  of  nitrogen  and 
particularly  quantitative  estimations  of  urea  and  in- 
coagulable nitrogen  in  the  blood  serum  are  of  much 
greater  significance  in  the  estimation  of  kidney  function 
than  the  same  or  related  studies  applied  to  the  urine. 

Diminished  and  Delayed  Excretion  of  Urea. — This 
is  an  old  criterion  of  functional  renal  power.  The 
physiological  principles  upon  which  it  is  based  have 
just  been  given.  In  order  that  this  test  of  renal  func- 
tion shall  be  really  conclusive,  the  patient  must  be  put 
for  some  days  upon  a  fixed  regimen  in  which  the  amount 
of  protein  is  definitely  known. 

The  feces  and  urine  must  be  examined  to  determine 
what  part  of  the  nitrogen  has  escaped  in  both.  In 
carrying  out  such  procedure,  the  experiment  rises  to 
the  dignity  of  a  metabolic  investigation  and  requires 
great  care  and  patience  besides  considerable  technical 
skill.  For  this  reason  such  a  procedure  cannot  be  re- 
garded as  adapted  to  clinical  use. 


Tests  of  Kidney  Function  83 

Without  the  above  precautions  the  value  of  ordinary 
routine  urea  estimation  in  the  urine  as  a  criterion  of 
renal  function  is  extremely  doubtful. 

If  the  dietary  conditions  can  be  reasonably  con- 
trolled and  a  perfectly  and  persistently  normal  output 
of  urea  results,  the  renal  function  is  at  least  equal  to 
the  ordinary  demand  of  that  person.  If  the  proteid 
intake  is  increased  and  the  urea  excretion  undergoes 
a  corresponding  and  immediate  rise,  it  may  be  con- 
cluded that  the  reserve  force  of  the  kidney  is  not 
materially  damaged. 

But  negative  results  need  not  necessarily  be  taken 
to  indicate  a  defect  of  renal  function  because  of  the 
fact  that  digestive  disturbance  and  diminished  liver 
function  will  cause  the  same  thing  to  occur.  If  these 
extrarenal  factors  of  error  can  be  eliminated,  then  a 
diminished  output  of  urea  may  become  a  valuable  and 
reliable  index  of  renal  inadequacy. 

Under  a  later  chapter,  concerning  study  of  the  blood 
as  an  index  of  renal  function,  it  will  be  shown  that  the 
quantitative  estimation  of  nitrogen  partition  in  that 
fluid  is  a  much  more  reliable  test  of  renal  functional 
power  than  urea  estimations  in  the  urine. 

Repeating  what  has  been  given  under  general  con- 
siderations it  may  be  stated  that  a  normal  adult  se- 
cretes from  30  to  34  grams  of  urea  in  the  urine  every  24 
hours. 

The  simplest  quantitative  test  for  urea  in  urine  is 
that  of  Marshall,  which  has  been  described  (v.  s.}. 
This  method  is  so  simple  and  so  accurate  that  every 
clinician  should  familiarize  himself  with  it. 

Forced  Urea  Elimination.  Provocative  Urea  Test  of 
McKasky. — Technic-  Thirty  grams  of  urea  dissolved 
in  four  to  six  ounces  of  water  are  given  with  a  small 


84      Manual  of  Vital  Function  Testing  Methods 

breakfast,  such  as  a  cup  of  gruel.  Follow  this  with 
four  or  five  ounces  of  water  to  assist  diuresis.  The 
urine  is  collected  every  two  hours  for  twenty-four  hours, 
beginning  two  hours  before  the  urea  is  given,  so  that  a 
standard  for  comparison  may  be  had,  to  determine  the 
amount  of  increase.  Quantitative  determinations  of 
urea  are  made  in  the  different  specimens  at  the  end  of 
the  time. 

The  maximum  excretion,  its  time,  incidence,  and  the 
curve  for  the  24  hours,  is  thus  determined. 

Under  normal  conditions  there  is  a  sharp  rise  in 
urea  excretion  in  the  second  two-hour  period.  When 
the  kidney  function  is  deficient  the  sharp  rise  is  absent 
or  is  much  delayed. 

The  only  factor  liable  to  disturb  the  interpretation 
of  this  test  is  gastric  stasis. 

Theoretically,  the  provocative  urea  test  should  be 
useful.  There  does  not  appear  to  be  any  reason  why 
the  urea  could  not  be  injected  in  smaller  amounts,  di- 
rectly into  the  circulation,  in  which  event  the  liability 
of  misinterpretation  through  retention  in  the  stomach 
would  be  avoided.  The  test  has  not  been  subjected  to 
any  clinical  examination,  so  far  as  I  know. 

4-     Estimation  of  Urinary  Coloring  Matter  as  Test 
of  Renal  Function 

Thudichum's  Test. — This  test  is  now  of  only  histor- 
ical interest.  It  was  proposed  by  its  author  on  the 
clinical  ground  that  in  many  chronic  kidney  diseases 
the  urine  becomes  distinctly  paler  in  color.  Therefore 
careful  quantitative  estimations  of  color  excretion 
might  be  of  value  as  an  early  sign  of  renal  imper- 
meability. But  unfortunately  for  the  value  of  the  test, 
the  quantity  of  coloring  matter  excreted  in  the  urine 


Tests  of  Kidney  Function  85 

depends  upon  a  great  variety  of  factors  (liver,  intes- 
tine, food,  etc.),  of  which  the  most  insignificant  of  all 
is  perhaps  renal  permeability. 

5.     Estimation   of  Urinary  Diastase  as  an  Index  of 
Renal  Function 

Wohlgemuth's  Test? — Te clinic.  After  neutraliza- 
tion urine  is  placed  by  means  of  an  accurately  grad- 
uated pipette  in  a  series  of  twelve  test  tubes,  the  amount 
decreasing  from  .6  c.c.,  .5  c.c.,  A  c.c.,  to  .1  to  .09  c.c., 
.08  c.c.,  to  .04  c.c.  A  sufficient  quantity  of  1%  sodium 
chloride  solution  is  then  added,  to  bring  the  amount  of 
fluid  in  each  tube  up  to  1  c.c.  In  order  to  more  readily 
obtain  the  fractional  quantity  of  urine  required,  1  c.c. 
of  the  urine  may  be  diluted  up  to  10  c.c.  and  from  this 
diluted  urine  the  required  measures  may  be  taken. 

To  each  tube  is  added  2  c.c.  of  a  1-1000  solution  of 
freshly  prepared  soluble  starch.  The  tubes  are  im- 
mersed in  a  water  bath  at  38°  C.  for  30  minutes,  after 
which  they  are  placed  in  cold  water  for  3  minutes. 

To  each  tube  is  then  added  sufficient  1/50  normal 
iodin  solution  to  elicit  a  permanent  color,  violet  or  blue 
occurring  where  digestion  is  not  complete. 

The  tube  in  the  series  immediately  preceding  incom- 
plete digestion  of  the  starch  indicates  the  diastase 
content  of  that  particular  urine.  From  this  is  calcula- 
ted the  diastasic  activity  represented  by  8.  8  is  expressed 
as  the  number  of  c.c.  of  1/10%  starch  solution  which 
can  be  digested  by  1  c.c.  of  urine.  This  test  can  be 
applied  to  the  whole  urine  or  to  the  samples  obtained 
unilaterally  by  ureteral  catheterization.  The  diastase 
test  is  particularly  adapted  to  unilateral  estimations 
of  kidney  function  applied  to  urine  obtained  by  ureteral 
3  Lancet  Clinic,  1913,  CX,  p.  164. 


86      Manual  of  Vital  Function  Testing  Methods 

catheterization.  But  altho  it  is  capable  of  indicating 
in  the  majority  of  cases  which  is  the  diseased  or  more 
diseased  kidney,  in  the  opinion  of  most  genitourinary 
surgeons  it  is  not  necessary  and  adds  nothing  to  the 
information  obtained  from  the  phthalein  test  or  urea 
estimations,  which  latter  are  operations  somewhat  more 
easily  performed. 

The  diastase  test  has  never  been  used  to  any  extent 
in  estimating  total  functional  capacity  of  the  kidneys. 

B.     The  Study  of  Physical  and  Biological  Character- 
istics of  the  Urine  as  Criteria  of  Renal  Function. 

There  are  three  tests  which  come  under  this  category : 

1.  Cryoscopy  or  determination  of  the  freezing  point 
of  the  urine. 

2.  Electrical  conductivity  of  the  urine. 

3.  Determination  of  urinary  toxicity. 

1.     Cryoscopy  of  the  Urine.   Significance  for  Estimat- 
mg  Renal  Function.     Von  KoranyVs  Test 

The  theoretical  bases  upon  which  this  test  is  founded 
are  of  extreme  interest  both  from  physical  and  physio- 
logical points  of  view  but  naturally  cannot  be  com- 
pletely considered  here. 

The  freezing  point  of  distilled  water  is  zero.  The 
freezing  point  of  any  solution  is  below  zero,  and  the 
depression  of  freezing  point  below  zero  is  proportionate 
to  the  molecular  concentration  of  the  solution.  Conse- 
quently the  freezing  point  of  a  solution  is  a  measure  of 
its  molecular  concentration.  It  is  also  a  measure  of  its 
osmotic  pressure. 

The  freezing  point  of  a  solution  is  independent  of 
the  nature,  size,  and  molecular  weight  of  the  dissolved 


Tests  of  Kidney  Function  87 

molecules  and  is  only  dependent  on  their  number.  The 
specific  gravity  of  a  solution  is  on  the  contrary  de- 
pendent upon  the  nature  and  molecular  weight  of  the 
dissolved  molecules.  Solutions  of  similar  molecular  con- 
centration have  the  same  freezing  point  and  the  same 
osmotic  pressure  but  not  necessarily  the  same  specific 
gravity. 

By  cryoscopy  the  molecular  concentration  of  urine 
and  blood  can  be  estimated  and  in  this  way  a  certain 
insight  into  the  functional  power  of  the  kidney  can  be 
obtained,  since  the  global  function  of  this  organ  is  to 
regulate  the  osmotic  pressure,  or,  what  is  the  same, 
the  molecular  concentration  of  the  blood.  One  can 
obtain  from  an  estimation  of  the  lowering  of  the  freez- 
ing point  of  the  urine  below  the  zero  of  distilled  water 
a  somewhat  more  adequate  idea  of  the  functional  ca- 
pacity of  the  kidney  than  from  the  specific  gravity.4 

Of  two  urines  of  equal  specific  gravity  the  one  with 
the  lower  freezing  point  comes  from  the  better  func- 
tioning kidney. 

Investigations  have  shown  that  the  freezing  point 
of  the  urine  (  A  )  in  health  varies  between  rather  wide 
limits  (A=  —.90°  to  — 2.30°)  and  that  it  is  to 
some  extent  affected  by  miscellaneous  factors  of  extra- 
renal  nature. 

Altho  much  was  expected  originally  from  the  de- 
termination of  the  freezing  point  (cryoscopy)  of  urine 
in  estimating  the  integrity  of  renal  function,  it  is  not 
depended  upon  to  any  great  extent  at  present. 

The  molecular  concentration  of  the  blood  hence  its 
freezing  point  (  8  )  is  much  more  constant  than  that 
of  the  urine.  It  is  supposed  to  remain  somewhere 

4  Some  authors  do  not  agree  that  cryoscopy  is  superior  to  sp. 
gr.  estimation  in  determining  renal  permeability,  v.  Sahli,  Diag- 
nostic Methods,  1905,  p.  551. 


88      Manual  of  Vital  Function  Testing  Methods 

near  — .56°.  It  was  thought  that  insufficiency  of  renal 
function  by  allowing  the  accumulation  of  molecules 
in  the  blood  which  should  be  excreted  would  raise  the 
molecular  concentration  therein  or,  in  other  words, 
lower  the  freezing  point.  Unfortunately,  experience 
has  not  confirmed  the  hopes  of  those  who  thought  that 
cryoscopic  examinations  of  the  urine  and  blood  would 
solve  the  great  problem  of  estimating  the  renal  func- 
tions and  the  method  is  not  extensively  used. 

The  relation  between  the  lowering  of  freezing  point 
of  blood  (&  )  and  urine  (A)  was  proposed  by  Dreser  as 
a  measure  of  the  work  done  by  the  kidney  and  by 
Bernard  as  the  basis  of  a  sort  of  mathematical  con- 
ception of  the  eliminatory  power  of  the  kidney.  The 
g 

formula    —  X  V  =  R    will    represent    the    molecular 

A 

elimination  of  the  kidney  according  to  this  conception. 
A  represents  the  freezing  point  of  urine,  8  that  of 
the  blood,  V  the  quantity  of  urine  in  24  hours.  In 
normal  cases  R  varies  from  3000  to  5000,  whereas  in 
renal  insufficiency  these  numbers  are  considerably  re- 
duced. Unfortunately  all  attempts  to  reduce  our  con- 
ceptions of  organic  function  to  mathematical  terms 
have  not  been  eminently  successful. 

Technic  of  Cryoscopy.- — The  technic  of  cr}roscopy 
is  not  especially  complex  but  requires  a  certain  ap- 
paratus for  its  performance.  It  is  usually  carried 
out  in  the  laboratory  and  has  never  become  a  routine 
clinical  procedure.  Only  the  necessary  outlines  of 
the  method  need  here  be  given  since  those  who  desire 
to  master  it  can  easily  refer  to  numerous  texts  in 
which  the  technique  is  minutely  described.5 

The  technic  of  cryoscopy  is  carried  out  with  Beck- 

B  Consult  in  this  connection  Wood's  Chemical  and  Microscopical 
Diagnosis,  1909,  p.  61;  Sahli's  Diagnostic  Methods,  p.  546. 


Tests  of  Kidney  Function  89 

mann's  freezing  apparatus  carrying  a  special  ther- 
mometer. The  freezing  mixture  is  made  of  ice,  water 
and  salt.  In  the  freezing  mixture  is  plunged  an  ordi- 
nary thermometer  and  a  mixer,  thus  enabling  the  tem- 
perature to  be  kept  at  a  fixed  point  ( — 3°  to  — 5°). 
Thro  an  opening  a  tube  containing  the  special  ther- 
mometer immersed  in  the  liquid  to  be  frozen  can  be 
immersed  in  the  freezing  mixture.  The  estimation 
of  the  exact  points  of  freezing  is  not  difficult  and 
usually  the  operation  can  be  performed  in  its  entirety 
in  15  or  20  minutes. 

2.     Electrical  Conductivity  of  the  Urine 

The  electrical  conductivity  of  the  urine  in  health 
and  disease  was  first  studied  by  Turner.  The  electrical 
conductivity  is  estimated  in  ohms  of  resistance  and 
depends  upon  the  number  of  ions  of  salts  dissolved 
in  the  urine.  The  method  measures,  in  other  words, 
the  amount  of  salts  or  mineral  content  of  the  fluid. 
The  Kohlrausch  method  of  performing  the  test,  which 
is  the  one  usually  employed,  requires  a  whetstone 
bridge,  a  resistance  box,  telephone  and  cells,  besides 
other  paraphernalia,  and  partly  on  account  of  this 
complexity  and  also  the  fact  that  the  practical  results 
obtained  are  meagre,  the  test  has  never  come  into  gen- 
eral use. 

3.     Estimation  of  Urinary  Toxicity  as  a  Test  of  Renal 
Function 

Bouchard's  Test.- — It  was  for  a  long  time  believed 
that  the  toxicity  of  the  urine  was  proportional  to  the 
functional  power  of  the  kidney.  Urine  of  human  be- 
ings produces  symptoms  of  poisoning  and  death  when 


90      Manual  of  Vital  Function  Testing  Methods 

injected  intravenously  into  lower  animals.  Bouchard 
developed  from  this  fact  a  method  of  testing  renal 
function  6  by  determining  the  quantity  of  a  24-hour 
specimen  of  urine,  required  to  kill  a  kilogram  of  lower 
animal.  Bouchard  established  a  so-called  urotoxic  co- 
efficient which  was  that  quantity  of  poison  elaborated 
by  every  kilogram  of  body  weight  of  the  person  whose 
urine  was  tested. 

The  same  objections  exist  with  respect  to  the  theo- 
retical basis  of  this  test,  as  in  the  case  of  chemical 
urinalysis  previously  discussed,  namely  that  so  many 
factors  besides  renal  sufficiency  or  insufficiency  enter 
into  the  production  of  results  that  the  test  becomes 
devoid  of  scientific  value.  It  simply  shows  the  toxicity 
of  a  given  urine  injected  intravenously  into  a  given 
animal  and  by  no  means  reflects  the  actual  functional 
power  of  the  kidney  thro  which  it  was  derived.  The 
test  is  quite  complex  and  has  been  abandoned. 

II.  STUDIES  OF  THE  BLOOD  AS  CRITERIA  OF  RENAL 
FUNCTION.  ESTIMATION  OF  BLOOD  UREA  AND  OF  IN- 
COAGULABLE (RESIDUAL)  NITROGEN  IN  BLOOD 

When  it  is  considered  that  a  major  portion  of  the 
nitrogenous  waste  of  the  body  makes  its  escape  thro 
the  kidney  by  way  of  the  urine,  it  becomes  evident  that 
a  diminution  of  the  functional  capacity  of  these  organs 
must  often  result  in  an  accumulation  of  nitrogenous 
products  of  metabolism  in  the  blood. 

Such  an  idea  is  very  old  and  as  long  ago  as  1821 
Prcvost  and  Dumas  "  reported  an  increase  of  urea  in 
the  blood  after  extirpation  of  the  kidneys  in  animals. 

8  Also  toxopexic  liver  function   (y. .?.). 

1  Quoted  by  Schondorff  in  Pfliiger's  Archiv  f.  de  ges.  Physiol., 
1899,  LXXIV,  p.  307. 


Tests  of  Kidney  Function  91 

The  clinical  importance  of  their  experiments  was  rec- 
ognized by  Bright  in  his  observations  upon  nephritis 
in  1836.8 

After  B right's  time  it  became  well  recognized  that 
in  chronic  nephritis  there  may  be  a  tendency  toward 
accumulation  of  nitrogenous  matters  in  the  blood,  but 
the  quantitative  study  of  nitrogen  retention  was  forced 
to  await  the  development  of  accurate  chemical  methods 
of  investigation.  In  this  place  we  can  speak  only  of 
modern  technic. 

The  development  of  accurate  technic  in  nitrogen 
estimation  of  the  blood  and  its  application  to  clinical 
medicine  is  a  subject  which  has  been  perfected  only 
since  the  beginning  of  the  century.  Ascoli,9  Strauss  10 
and  others  showed  that  in  many  cases  of  chronic 
Bright's  disease  nitrogenous  matter  accumulates  in  the 
blood  and  the  increase  is  more  marked  as  death  ap- 
proaches. Muller  1:  showed  that  in  outspoken  uremia 
the  accumulation  becomes  proportionately  more 
marked. 

Obermayer  and  Popper  12  first  laid  stress  upon  the 
increase  of  incoagulable  nitrogen  in  the  blood  serum 
in  uremic  states  and  found  that  in  this  incoagulable 
nitrogen  increase,  urea  plays  the  most  important  part. 
Hohlweg13  substantiated  these  facts  and  altho  he 
showed  that  an  increase  of  urea  in  the  blood  is  not 
necessarily  pathognomonic  of  uremia,  nevertheless  its 
accumulation  therein  may  be  regarded  as  an  evidence 
and  to  some  extent  at  least  as  an  index  of  the  function 

s  Guy's  Hosp.  Rep.,  1836,  I,  p.  358. 

u  Pfluger's  Arch.  f.  de  ges.  Physiol.,  1901,  LXXXVII,  p.  103. 
10  Chronisch   Nierenenzundung;   ihrer   Eimvirkung  auf  die   Blut- 
flussigkeit,  etc.,  Berlin,  1902. 

"Verb.   d.  Deutsch.  path.  Gesell.,  1904-5,  VII  to  IX,   Erg.  80. 
"Zeit.  f.  klin.  Med.,  1909,  LXVII,  p.  332. 
MDeut.  Archiv  f.  klin.  Med.,  1912,  CIV,  p.  216. 


92      Manijuil  of  Vital  Function  Testing  Methods 

of  the  kidneys. 

Widal,14  however,  believes  that  the  amount  of  urea 
retention  is  an  actual  quantitative  index  of  renal  func- 
tion and  that  the  severity  and  prognosis  of  a  given 
case  may  be  predicated  upon  the  basis  of  such  findings. 
Widal's  clinical  method  of  estimating  urea  in  the  blood 
is  not  commonly  used  in  this  country  as  it  gives,  ac- 
cording to  Rowntree  and  Fitz,  an  error  of  10  to  60% 
and  is  therefore  useless  as  a  quantitative  method. 

The  estimation  of  urea  in  blood  serum  has  remained 
until  recently  a  rather  difficult  chemical  operation,  but 
of  late  one  or  two  practical  clinical  methods  have  been 
devised  which  render  the  test  much  more  practical. 
Marshall's  method  appears  to  be  the  simplest  and 
most  practical  of  these  and  will  he  described  in  full 

(».*.). 

The  normal  figures  for  the  elimination  of  urea  are 
between  .300  to  .500  gm.  per  liter  of  serum. 

The  simplest  methods  by  which  the  total  incoagulable 
nitrogen  in  the  blood  serum  may  be  determined  still 
remain  even  more  difficult  and  complicated  than  those 
of  urea  estimation,  especially  since  they  involve  in  the 
end  a  nitrogen  determination  by  Kjeldahl's  method.  A 
fair  laboratory  equipment  is  therefore  necessary. 

The  most  practical  method  of  determining  the  in- 
coagulable nitrogen  seems  to  be  that  of  Hohlweg 
and  Meyer  which  has  been  modified  by  Morris  ]r>  in 
this  country.  This  method  will  be  described  below. 
The  normal  figures  for  total  incoagulable  nitrogen  in 
the  blood  serum  are  .500  to  .600  gm.  per  liter. 

The  recent  work  of  Folin  and  Denis  indicates  that 
a  urea  concentration  in  the  blood  of  .5  gm.  and  total  in- 

14  Bull,  et  Mem.  Soc.  Med.  d.  hop.  de  Paris,  3,  1011,  XXXTI,  p. 
627. 
15Archiv.  of  Int.  Med.,  1911,  VIII,  p.  457. 


Tests  of  Kidney  Function  93 

coagulable  nitrogen  content  of  .6  gm.  per  liter,  which 
was  formerly  considered  normal,  is  too  high  an  esti- 
mate. They  found  the  normal  urea  concentration  .13 
gm.  and  incoagulable  nitrogen  .26  gm.  per  liter.  In 
their  experience  no  great  prognostic  significance  is  to 
be  attached  to  urea  concentration  of  less  than  .55  gm. 
per  liter  and  incoagulable  nitrogen  less  than  .50  gm. 
per  liter.  Greater  concentration  than  this,  especially 
if  the  freezing  point  of  the  serum  drops  lower  than 
— 60  are  of  considerable  prognostic  significance. 

In  pure  passive  congestion  Rowntree  states  that  he 
has  never  seen  the  rest  nitrogen  in  the  blood  serum 
higher  than  .63  gm.  per  liter. 

Marked  accumulation  of  incoagulable  nitrogen  or 
of  urea  in  the  blood  is  now  regarded  as  a  valuable 
evidence  of  renal  insufficiency  and  in  cases  of  nephritis 
it  is  an  unfavorable  prognostic  sign. 

The  relation  between  non-protein  (incoagulable)  ni- 
trogen retention  in  the  blood  and  the  excretion  of  phe- 
nolsulphonphthalein  has  been  studied  in  experimental 
uranium  nephritis  by  Frothingham,  Fitz,  Folin  and 
Denis.16  These  investigators  found  that  the  results  of 
the  two  tests  paralleled  very  closely.  For  this  reason 
and  because  in  clinical  studies  the  same  parallelism  has 
been  found  to  obtain,  these  two  tests  have  come  to  be 
considered  as  among  the  best  for  conjoint  use. 

It  will  now  be  necessary  to  give  the  simplest,  most 
practical  and  accurate  methods  by  which  the  clinical 
investigator  may  determine  the  two  important  phases 
of  the  blood  which  have  been  discussed,  namely,  the 
amount  of  urea  in  the  blood  and  the  amount  of  in- 
coagulable or  rest  nitrogen  contained  in  the  same  fluid. 
The  chemical  operations  which  are  used  at  present  for 
these  purposes  are  simple  enough  to  bring  about  their 

"Arch,   of   Int.   Med.,    1913,   XIII,   p.   2L5. 


94      Manual  of  Vital  Function  Testing  Methods 

frequent  use  in  the  clinic.  The  best  method  of  quickly 
and  accurately  determining  the  amount  of  urea  in  the 
blood  is  that  of  Marshall.  The  incoagulable  or  rest 
nitrogen  in  blood  serum  is  usually  determined  by  either 
of  two  general  methods,  that  of  Hohlweg-Meyer  and 
that  of  Folin  and  Denis.  The  details  of  these  three 
important  methods  will  now  be  given. 

Marshall's  Method  for  the  Determination  of  Urea 
in  the  Blood.17 — The  blood  is  drawn  in  the  usual  man- 
ner and  allowed  to  stand  on  ice  until  clotting  is  com- 
plete. As  shown  below,  the  urea  content  of  the  serum 
does  not  change  after  standing  even  for  three  or  four 
days ;  the  blood  can,  therefore,  be  kept  on  ice  over 
night,  if  desired. 

Two  equal  portions  of  the  serum  are  measured  into 
ordinary  test  tubes,  1  c.c.  of  the  soy  bean  extract lf 
added  to  one  tube,  and  about  0.5-1.0  c.c.  of  toluene  to 
each.  If  sufficient  serum  is  available,  10  c.c.  portions 
should  be  used;  however,  perfectly  satisfactory  results 
can  be  obtained  by  using  5  c.c.  or  even  3  c.c.  portions 
of  the  serum.  The  tubes  are  tightly  stoppered  and 
allowed  to  remain  at  room  temperature  until  the  con- 
version of  the  urea  into  ammonium  carbonate  is  com- 
plete. Generally,  they  are  allowed  to  stand  over  night, 
altho  four  to  five  hours  is  usually  amply  sufficient  for 
the  completion  of  the  reaction.  The  contents  of  the 
tube  containing  the  serum  and  extract  arc  transferred 
to  cylinder  A  (see  illustration),  and  washed  in  with  a 

"Jour,  of  Biol.  Chem.,  1913,  XV,  No.  3. 

18  The  preparation  of  the  soy  bean  extract  is  as  follows:  Ten 
grams  of  finely  ground  soy  beans  are  treated  with  100  c.c.  of  water 
and  allowed  to  stand  with  occasional  agitation  for  one  hour.  10  c.c. 
of  ^  hydrochloric  acid  are  added  and  the  mixture  allowed  to 
stand  about  fifteen  minutes  longer.  It  is  now  filtered  and  pre- 
served with  toluene.  Such  a  solution  is  perfectly  satisfactory  for 
use  at  least  five  or  six  days  after  its  preparation. 


Tests  of  Kidney  Function 


95 


very  small  amount  of  water  (not  more  than  5  c.c.). 
Two  grams  of  sodium  chloride,  an  equal  volume  of  al- 
cohol and  a  layer  of  kerosene  oil  are  added  to  the  cylin- 
der. The  contents  of  the  other  tube  are  transferred  to 


cylinder  B,  and  treated  in  exactly  the  same  manner.  25 
c.c.  of  -—  hydrochloric  acid  and  about  25  c.c.  of  water 

are  placed  in  each  of  the  200  c.c.  Erlenmeyer  flasks 
used  for  the  absorption  of  the  ammonia.  The  different 
parts  of  the  apparatus  are  now  connected  and  about  0.5 
gram  of  sodium  carbonate  added  to  each  cylinder.  A 
rapid  air  current  is  passed  through  the  apparatus  until 
all  the  ammonia  has  been  removed  from  the  cylinders. 
With  a  good  suction  pump,  one  hour  suffices.  The 

excess  of  acid  in  the  absorption  flasks  is  titrated  with  — 

OU 

sodium  hydroxide  and  alizarin  sodium  sulphonate.  The 
amount  of  acid  neutralized  in  the  flask  attached  to 


96      Manual  of  Vital  Function  Testing  Methods 

cylinder  B  corresponds,  of  course,  to  the  ammonia  10 
present  in  the  serum,  while  the  amount  used  in  the  other 
two  flasks  represents  the  urea  plus  the  ammonia.  The 

difference    corresponds    to   the   urea   in    terms    of   r-r 

OU 

hydrochloric  acid,  and  multiplied  by  0.0006  gives  the 
urea  in  grams  present  in  the  amount  of  serum  taken 
for  the  determination. 

Details  in  Connection  With  the  Apparatus  and  De- 
termination.— 1.  On  account  of  the  large  quantity  of 
protein  in  serum,  it  is  advisable  to  use  both  alcohol  and 
kerosene  to  prevent  foaming.20 

2.  The  tubes  C  and  C'  are  ordinary  calcium  chlor- 
ide drying  tubes  packed  loosely  with   cotton.      These 
in  conjunction  with  the  bulbs  prevent  any  splashing 
or  mechanical  transmission  of  the  alkali  into  the  ab- 
sorption  flasks.      While    the   bulbs    are    probably    not 
absolutely   necessary,   they  are   convenient  in  keeping 
the  cotton  filters  dry. 

3.  For  the  better  absorption  of  the  ammonia,  the 
tubes  in  the  Erlenmeyer  flasks  are  closed  at  one  end, 
and  pierced  with  six  or  seven  small  holes,  as  suggested 
by  Folin.'1     Even  with  this  device  one  absorption  flask 
is  not  always   sufficient  to  completely   absorb  the  am- 
monia.    Two  flasks  are  always  used  for  safety  in  con- 
nection   with   the    urea   determination;    however,    since 
from  the  serum  alone  only  a  very  small  amount  of  am- 
monia   (corresponding  to    0.10-0.70   c.c.    of  -^    HC1) 

oU 

19  We  can,  however,  place  no  value  on  this  as  a  determination  of 
the  true  ammonia  content  of  the  blood,  for  on  standing  even  a 
few  hours  tin1  blood  develops  much  more  ammonia  than  the 
original  amount  (Folin). 

!0  This  has  been  pointed  out  by  Folin,  in  connection  with  the  use 
of  the  air  current  method  for  determining  ammonia  in  blood. 
(Zeitsch.  f.  physiol.  Chem.,  XXXVII,  p.  !(>.>,  l!)OJ-0.'i.) 

-'Jour.  Biol.  Chem.,  XI,  p.  493,  19U. 


Tests  of  Kidney  Function  97 

is    ordinarily    obtained,    one    absorption   flask   is    here 
sufficient. 

4.  A  layer  of  toluene  is  placed  on  the  liquid  in  the 
absorption  flasks,  for.  due  probably  to  the  alcohol  car- 
ried over  by  the  air  current,  considerable  foaming  some- 
times occurs.     If  not  prevented,  this  results  in  a  loss 
of  a  portion  of  the  contents  of  the  flask. 

5.  The  bottle  contains  dilute  sulphuric  acid  to  free 
the  air  from  any  traces  of  ammonia  before  passing  it 
through  the  apparatus. 

6.  No  correction  is  necessary  for  the  ammonia  de- 
rived from  the  1  c.c.  of  soy  bean  extract  used,  as  the 
amount  obtained  from  this  source  is  unappreciable. 

Another  method  also  suggested  by  Dr.  Marshall  is 
to  draw  5  c.c.  of  blood  from  a  vein  with  a  hypodermic 
needle,  into  a  5  c.c.  pipette,  and  immediately  transfer 
the  specimen  to  a  test  tube,  containing  1  to  2  c.c.  of 
1%  sodium  oxalate  solution.  To  this  is  added  25 
milligrams  (one  tablet)  of  Urease-Dunning,  the  tablet 
having  been  previously  crushed  and  dissolved  in  5  c.c. 
of  water.  This  mixture  is  allowed  to  stand  until  the 
urea  of  the  blood  is  decomposed;  at  ordinary  room 
temperature,  one-half  an  hour  is  usually  sufficient;  it 
is  better,  however,  to  place  the  test  tube  in  a  beaker 
of  water  at  30°  to  40°  C.  for  one-half  hour.  After  the 
urea  has  been  changed,  the  contents  and  sufficient  wash- 
ings of  the  tube  are  transferred  to  a  cylinder.  The 
ammonia  is  then  removed  by  a  current  of  air  collected 

in    the    -        hydrochloric    acid    and    titrated  with 

50  50 

sodium  hydroxide. 

Calculating  Urea  Content.— As  the  purpose  in  using 
Urease-Dunning  is  to  convert  the  urea  present  in  a 
specimen  into  an  easily  estimated  substance — am- 
monium carbonate — and  as  the  amount  of  this  salt 


98      Manual  of  Vital  Function  Testing  Methods 

produced  from  this  source,  by  the  enzyme,  is  indicated 
by  the  increased  alkalinity  of  the  specimen  to  methyl 
orange,  it  is  obvious  that  the  quantity  of  standard 
hydrochloric  acid  required  to  exactly  neutralize  the 
contents  of  the  flask  containing  urease,  less  the  quan- 
tity required  for  the  control  specimen,  corresponds  to 
the  ammonium  carbonate  formed  by  the  conversion  of 
the  urea  originally  present  in  the  specimen. 
By  the  following  equation: 

NH2  ONH4 

CO         +2H20=CO 

NH2  ONH4 

it  may  be  calculated  that  60  grams  of  urea  would  be 
converted,  by  urease,  into  96  grams  of  ammonium  car- 
bonate, which  amount  would  require  72  grams  of  hydro- 
chloric acid  to  neutralize  it. 

As  this  quantity  (72  grams)  of  hydrochloric  acid 
is  contained  in  20,000  c.c.  of  decinormal  (N/10)  hydro- 
chloric acid  solution  and  is  equivalent  to  60  grams  of 
urea,  as  represented  by  96  grams  of  ammonium  car- 
bonate, it  follows  that  one  twenty-thousandth  of  this 
quantity  or  1  c.c.  of  decinormal  hydrochloric  acid 
would  be  equivalent  to  one  twenty-thousandth  of  60 
grams  =  3  milligrams  (60  -f-  20,000  =  .003),  there- 
fore each  c.c.  of  decinormal  hydrochloric  acid  required 
to  neutralize  an  enzyme-treated  specimen,  that  is  in 
excess  of  the  number  of  cubic  centimeters  required  to 
neutralize  the  control  specimen,  represents  three  milli- 
grams of  urea,  and,  as  the  5  c.c.  specimen  is  the  one 
two-hundredth  part  of  a  liter,  it  will  be  only  necessary 
to  multiply  the  number  of  c.c.  of  the  decinormal  hydro- 
chloric acid  solution,  in  excess  of  the  control's  require- 
ments, by  the  factor  .6  (.003  X  200  =  .6)  to  ascer- 
tain the  urea  per  liter,  when  estimating  the  daily  output. 


Tests  of  Kidney  Function  99 

1.     Technic  of  Estimating  Total  Incoagulable  or  So- 
catted  Rest  or  Residual  Nitrogen  in  the  Blood  Serum 

Two  methods  are  in  common  use.  These  are  Morris' 
modification  of  the  Hohlweg-Meyer  method,  and  the 
method  of  Folin  and  Denis. 

Morris'  Modification  of  Hohlweg-Meyer  Method. — 
To  10  c.c.  of  blood  serum  obtained  by  venipuncture  or 
otherwise,  in  a  300  c.c.  Erlenmeyer  flask  is  added  a 
reagent  consisting  of  equal  parts  of  1%  acetic  acid 
and  a  5%  solution  of  monocalcium  phosphate,  until  the 
reaction  is  acid  to  litmus  but  neutral  to  Congo  red. 
The  volume  is  brought  up  with  distilled  water  to  80 
c.c.  and  80  c.c.  of  saturated  solution  of  sodium  chloride 
are  poured  into  the  flask. 

The  mixture  is  boiled  to  precipitate  the  coagulable 
proteins,  and  the  filtrate,  from  which  the  proteins  have 
been  shown  to  be  completely  removed,  subjected  to  a 
nitrogen  determination  by  Kjeldahl's  method. 

For  a  description  of  the  technic  of  Kjeldahl's  method 
see  page  28. 

Folin  and  Denis  Method. — This  method  is  considered 
at  the  present  time  as  the  most  practical  way  of  quan- 
titatively determining  the  amount  of  rest  nitrogen  in 
the  blood.  It  will  be  given  in  the  words  of  its  authors 
from  their  communication  published  in  1912.  (Jour. 
Biol.  Chem.  1912,  XI,  527,  Ibid.  1913,  XIV,  29.) 

Method  for  Drawing  Blood. — "Before  going  into  de- 
tails of  the  chemical  work  it  would  seem  worth  while 
to  describe  our  method  of  drawing  blood  because  sc 
far  as  we  have  been  able  to  learn  it  is  somewhat  different 
from  the  procedures  employed  by  physiologists  and 
because  we  believe  it  to  be  expeditious,  neat  and  exact 
and  therefore  particularly  suitable  for  quantitative 
work. 


100      Manual  of  Vital  Function  Testing  Methods 

"We  use  neither  cannulae  nor  syringes  but  simply 
hypodermic  needles  and  pipettes.  The  needles  are  about 

1  mm.  in  diameter,  and  about  25  mm.  long.     They  are 
immersed  in  a  dilute  solution  of  vaseline  in  ether  and 
then  allowed  to  drain  and  dry  on  a  clean  paper  for 
a  few  minutes  before  being  used.     (This  does  not  apply 
of  course   to   the   drawing  of  human   blood   when   the 
needles  must  be  thoroughly  sterilized.)      An  adequate 
supply  of  these  needles  is  kept  on  hand  so  that  we  do 
not  need  to  use  any  needle  more  than  once  in  any  one 
experiment.      The  needle  is   attached  to  the  tip   of  a 

2  or  5  c.c.  pipette  by  means  of  a  short  piece  of  narrow 
pure  gum  tubing.     A  small  pinch  of  powdered  potas- 
sium oxalate  is  introduced  into  the  upper  end  of  the 
pipette  (which  must  be  clean  and  perfectly  dry)   and 
is  allowed  to  run  down  into  the  tip  and  the  needle.    The 
other  end   of  the  pipette  is  connected  with   a   rubber 
tube  which  in  turn   connects  with   a  mouthpiece  con- 
sisting of  a  short  tapering  glass  tube.     Close  to  the 
pipette  the  rubber  tube  carries  a  pinchcock. 

"To  draw  the  blood  insert  the  needle  in  the  vein  or 
artery  and  regulate  the  flow  of  the  blood  by  means  of 
the  pinchcock  and  by  suction.  The  exact  quantity  of 
blood  desired  is  thus  obtained  without  any  waste  and 
without  clotting." 

Isolation  of  Non-Protein  Nitrogenous  Constituents. 
— "To  separate  the  non-protein  nitrogenous  constitu- 
ents from  the  protein  materials  we  make  use  of  pure 
(acetone-free)  methyl  alcohol  and  an  alcoholic  solu- 
tion of  zinc  chloride.  Ordinary  methyl  alcohol  cannot 
be  used  because  the  impurities  in  it,  particularly  the 
acetone,  combine  Avith  more  or  less  of  the  urea  so  that 
it  escapes  decomposition  in  the  subsequent  treatment 
and  is  not  quantitatively  recovered.  We  have  satisfied 
ourselves  by  means  of  determinations  on  pure  urea 


Tests  of  Kidney  Function  101 

solutions  that  the  presence  of  acetone  results  in  a  loss 
of  urea. 

"As  soon  as  the  blood  is  drawn  it  is  transferred  into 
measuring  flasks  half  filled  with  methyl  alcohol  and  the 
flasks  are  then  filled  up  to  the  mark  with  methyl  alcohol 
and  vigorously  shaken.  Two  cubic  centimeters  of  blood 
are  diluted  to  25,  while  for  5  c.c.  of  blood  use  50  c.c. 
flasks.  At  the  end  of  two  hours,  or  as  soon  after  that  as 
is  convenient,  the  contents  of  the  flasks  are  filtered 
through  dry  filters.  To  the  filtrate  are  then  added  two 
or  three  drops  of  a  saturated  alcoholic  solution  of  zinc 
chloride  and  after  standing  for  a  few  minutes  the  mix- 
ture is  again  filtered  thro  a  dry  paper.  The  zinc  chlor- 
ide brings  down  an  appreciable  precipitate  and  the  last 
traces  of  coloring  matters  so  that  when  the  second 
filtration  is  made,  a  perfectly  colorless  filtrate  is  ob- 
tained. 5  c.c.  of  these  filtrates,  corresponding  to  0.4 
or  to  0.5  c.c.  of  blood,  depending  on  whether  2  or  5 
c.c.  of  blood  were  drawn,  are  taken  for  each  determina- 
tion. 

"The  precipitation  procedure  described  above  is  the 
one  which  we  ordinarily  use.  There  are  objections  to 
it.  We  are  not  certain  that  protein-like  materials  may 
not  escape  precipitation  by  this  as  by  every  other 
method  and  we  do  know  that  the  filtrate  does  not  con- 
tain all  of  the  non-protein  materials.  When  relatively 
large  quantities  (equivalent  to  100  mgm.  of  nitrogen 
per  100  c.c.  of  blood)  of  creatine  or  asparagine  are 
added  to  blood  and  treated  as  described  above  there  is 
invariably  an  appreciable  loss  of  material.  To  over- 
come this  loss  we  have  tried  to  triturate  and  wash  the 
first  alcoholic  precipitate  with  methyl  alcohol,  and  with 
some  substance  as,  for  example,  with  glycocoll,  urea 
and  acetamide,  we  are  thus  able  to  get  practically 
quantitative  results,  while  with  others,  such  as  creatine, 


Manual  of  Vital  Function  Testing  Methods 

asparagine  and  tyrosine,  we  still  do  not  get  quite  all. 
Moreover,  such  trituration  and  washing  docs  leach  out 
a  small  amount  of  the  coloring  matters  of  the  blood 
so  that  except  for  special  experiments  with  less  soluble 
substances  we  consider  the  simpler  procedure  rather 
more  satisfactory. 

Determination  of  the  Total  Non-Protein  Nitrogen. — 
"To  determine  the  non-protein  nitrogen  of  the  blood 
5  c.c.  of  the  alcoholic  filtrate  is  transferred  to  a  large 
Jena  test  tube.  One  drop  of  sulphuric  acid,  one  of 
kerosene  and  a  pebble  are  added  and  the  methyl  alcohol 
is  driven  off  by  immersing  the  test  tube  in  a  beaker 
of  boiling  water  for  five  to  ten  minutes.  When  the 
alcohol  is  removed  1  c.c.  of  concentrated  sulphuric 
acid,  a  gram  of  potassium  sulphate,  and  a  drop  of 
copper  sulphate  solution  are  added  and  the  mixture  is 
boiled,  cooled  and  diluted. 

"From  this  digestion  mixture  the  ammonia  is  removed 
in  the  usual  manner.  It  is,  however,  not  collected  di- 
rectly in  a  measuring  flask  (as  in  urine  analysis)  but 
in  a  second  large  test  tube  previously  charged  with  1 

c.c.  of  —  acid  added  to  3  c.c.  of  water.     The  reason 

for  this  variation  is  that  0.4  to  0.5  c.c.  of  blood  con- 
tains only  0.1  to  0.2  mgm.  of  non-protein  nitrogen. 
The  final  Nesslerizcd  solution  cannot  be  diluted  to  100 
c.c.  and  smaller  volumetric  flasks  cannot  be  used  as  re- 
ceivers during  the  air  current  treatment  because  of 
spattering.  Large  test  tubes  are  therefore  used  as 
receivers  and  the  ammonia  is  Nesslcrized  in  these  before 
the  liquids  are  transferred  to  measuring  flasks. 

"Ordinarily  the  colored  solutions  when  obtained  from 
cat's  blood  are  transferred  to  25  c.c.  flasks  and  are  then 
found  to  have  a  depth  of  color  which  permits  of  a 
sure  and  accurate  reading  in  the  colorimeter.  In  some 


Tests  of  Kidney  Function  103 

of  our  absorption  experiments  the  total  non-protein 
nitrogen  runs  up  to  very  high  figures  and  then  the  solu- 
tions are  diluted  to  50,  sometimes  even  to  100  c.c.,  be- 
fore being  read  in  the  colorimeter. 

"Human  blood  contains  scarcely  more  than  one-half 
as  much  non-protein  nitrogen  as  cat's  blood.  In  the 
case  of  human  blood  we  therefore  never  draw  less  than 
5  c.c.  and  we  take  10  c.c.  of  the  filtrate  for  each  de- 
termination. In  all  other  respects  we  use  the  same 
procedure  for  human  blood  as  for  cat's  blood. 

"In  all  ordinary  cases  7  to  8  c.c.  of  diluted  Nessler's 
reagent  (dilution  1:5)  are  added  for  the  production 
of  the  color.  If  much  ammonia  is  present  so  that  the 
resulting  colored  solution  must  be  diluted  to  50  or  100 
c.c.  correspondingly  larger  amounts  of  Nessler's  reagent 
are  added. 

"The  calculation  of  the  analytical  results  to  milli- 
grams of  nitrogen  per  100  c.c.  of  blood  is  not  difficult, 
but  the  formulae  given  below  may  prove  useful.  In 
these  formulae,  the  standard  solution  contains  1  mgm. 
of  nitrogen  (as  ammonium  sulphate)  Nesslerized  in  a 
100  c.c.  flask  and  the  colorimeter  prism  of  the  standard 

50 

is  set  at  20  millimeters.      ^-  X  D,  in  which  R  stands 

XV 

for  the  reading  of  the  unknown  and  D  represents  the 
volume  to  which  its  ammonia  has  been  diluted,  gives 
the  desired  figure.  The  reason  for  the  figures  is  that 
we  are  working  with  4  c.c.  of  blood. 

"When  5  c.c.  of  blood  is  taken  and  it  is  diluted  to  50, 

40 

the   formula  becomes   -=?  X  D- 
xv 

"When  working  with  human  blood  and  taking  10  c.c. 
of  the  filtrate  obtained  from  5  c.c.  of  blood  diluted  to 

20 

50  the  formula  is  —  X  D- 
xv 


104      Manual  of  Vital  Function  Testing  Methods 

"It  may  be  thought  that  we  are  using  unnecessarily 
small  amounts  of  blood  in  these  analyses.  We  are, 
however,  by  no  means  sure  that  working  with  larger 
amounts  would  yield  more  accurate  results  and  we  have 
satisfied  ourselves  by  scores  of  duplicate  analyses  that 
the  method  as  outlined  gives  trustworthy  figures. 
Further,  the  smaller  the  quantity  of  blood  which  can 
be  made  to  give  reliable  results  the  greater  becomes 
the  usefulness  of  the  method.  The  work  which  we 
have  already  done  on  cats  could  not  have  been  done 
on  such  a  small  animal  except  by  means  of  these  micro- 
chemical  methods.  Finally,  small  amounts  of  blood 
must  be  used  for  the  urea  determinations  because  of 
the  disturbing  effects  of  the  sugar  present." 

2.     Estimation  of  Blood  Coagulation  Time  as  Test  of 
Renal  Function 

Bachrach-Tittinger  Test. — In  cases  of  renal  insuf- 
ficiency, such  cases  as  those  in  which  it  is  claimed  that 
the  freezing  point  of  the  blood  is  lowered  (high  fig- 
ures for  8  )  the  coagulation  time  has  been  found  de- 
layed. This  delay  is  supposed  to  be  connected  with  salt 
retention  in  the  plasma.  A  rather  large  amount  of 
blood  is  required  according  to  the  original  technic  of  the 
originators  (20  c.c.).  The  test  is  not  credited  with 
much  value. 

For  method  of  estimating  blood  coagulation  time 
see  page  41. 

3.     Cryoscopy  of  Blood  as  Test  of  Renal  Function 

Cryoscopy  of  the  Blood. — This  method  has  been 
employed  by  some  investigators  on  the  principle  that 
under  conditions  of  renal  impermeability  the  waste 


Tests  of  Kidney  Function  105 

products  which  fail  to  be  eliminated  in  the  urine  will 
accumulate  in  the  blood,  thereby  increasing  the  molecu- 
lar concentration.  This  means,  of  course,  a  lowering 
of  its  freezing  point. 

The  technic  of  estimating  cryoscopy  of  the  blood  is 
not  different  from  that  applied  to  the  urine,  which 
has  been  already  described  (v.  page  86).  This  method 
has  not  come  into  general  use,  however,  and  for  this 
reason  it  will  not  be  further  considered  here. 


III.  STUDY  OF  THE  ELIMINATION  OF  FOREIGN  SUB- 
STANCES BY  THE  KIDNEY,  AS  CRITERION  OF  KIDNEY 
FUNCTION 

This  category  of  tests  may  be  divided  into  two  parts : 

A.  Miscellaneous  Chemical  Substances : 

1.  Potassium  iodide. 

2.  Phloridzin. 

3.  Hippuric  acid. 

4.  Lactose. 

B.  Elimination  of  Dyes  by  the  Kidney. 

1.  Methylcne  blue. 

2.  Indigo  carmin. 

3.  Phenolsulphonephthalein. 

CHEMICAL    TESTS 

A.     Tests  with  miscellaneous  chemical  substances. 

1.     The  Potassium  Iodide  Test 

This  was  one  of  the  first  chemical  substances  applied 
to  the  estimation  of  renal  function  since  it  was  sug- 
gested by  Duckworth  as  long  ago  as  1867. 22 

22  St.  Barthol.  Hosp.  Rep.,  1867,  III,  216. 


106      Manual  of  Vital  Function  Testing  Methods 

Potassium  iodide  is  rapidly  absorbed  from  all  the 
mucous  membranes.23  It  is  absorbed  unchanged  and 
appears  quickly  in  the  excretions.  Only  a  few  min- 
utes normally  elapse  before  it  can  be  demonstrated  in 
the  urine.  According  to  the  investigations  of 
Quetsch,24  Roux  25  and  Studeni  26  it  appears  at  any 
time  from  9  to  18  minutes  after  doses  of  1  to  3  grams 
have  been  swallowed.  The  greater  part  of  the  iodide 
ingested  is  excreted  in  the  urine.  Some,  however,  es- 
capes in  the  saliva  and  other  secretions. 

Iodide  is  rapidly  excreted,  since  65-80%  of  the 
amount  ingested  is  eliminated  in  24  hours.  Several 
investigators  have  reported  the  exact  time  required 
for  complete  elimination  to  take  place.  According  to 
Antem,27  .5  gram  requires  40  hours  to  be  excreted,  and 
Schlayer  and  Takayasu,28  and  Monakow  29  state  that 
they  found  the  same  amount  required  48  hours  to 
eliminate.  Schlayer  concluded  from  his  studies  that 
the  demonstration  of  iodide  in  the  urine  beyond  60 
hours  after  its  administration  may  be  considered  de- 
layed, therefore  a  pathological  excretion. 

Schlayer  and  his  followers  endeavored  to  fix  as  they 
did  with  sodium  chloride  the  exact  locus  of  elimination 
for  iodide  in  the  kidney.  They  believed  that  iodides  are 
excreted  by  the  tubular  epithelium.  They  also  con- 
tended that  the  elimination  of  iodide  is  not  delayed 
in  passive  congestion  (cardiac)  while  it  is  delayed 
in  chronic  tubular  nephritis.  These  suppositions  have 
neither  of  them  been  substantiated  by  subsequent  in- 

23  Gushing  Pharmacology,  5  Ed.,  1910,  510. 

M  Berl.  klin.  Wchnschr.,'  1884,  XXI,  353. 

28  Thfcse  de  Paris,  1890,  no.  248. 

20  Inaugural  Dissertat.,  Zurich,  1897. 

27  Arch.  f.  Pathol.  u.  Pharmacol.,  1902,  XL VIII. 

'"Deutsch.   Arch.   f.  klin.  Med.,   1911,  CI,  354. 

""Deutsch.  Arch.  f.  klin.  Med.,  CII,  248. 


Tests  of  Kidney  Function  107 

vestigations. 

Rowntree  and  Fitz  in  their  experience  with  the  iodide 
test  have  found  it  to  vary  markedly  and  they  believe 
that  the  observation  of  excretion  time  of  potassium 
iodide  as  a  test  of  renal  function  is  unreliable. 

Technic  of  Iodide  Test. — .5  gm.  (7^  grains)  of 
potassium  iodide  is  given  in  solution  by  mouth  in 
the  morning  on  arising.  The  urine  is  collected  at  the 
end  of  48  hours  and  every  four  hours  thereafter  and 
tested  for  iodide  until  a  negative  result  is  obtained. 

One  of  the  simplest  and  best  qualitative  tests  for 
iodide  in  the  urine  is  that  of  Sandow.  The  test  is 
made  by  taking  30  c.c.  of  urine,  2  c.c.  of  2%  solution 
of  sodium  nitrate  and  2  c.c.  of  dilute  sulphuric  acid, 
adding  chloroform  and  shaking.  A  purplish  or  violet 
color  appears  in  the  chloroform  if  iodide  is  present. 

2.     The  Phloridzin  Test 

Von  Mering  30  discovered  the  fact  that  the  injection 
of  the  glucoside  phloridzin  into  animals,  produces  a 
glycosuria  without  a  hyperglycemia,  thus  proving  that 
the  conversion  is  a  vital  act  of  the  renal  parenchyma. 
Achard  and  Delamare  31  built  upon  this  fact  a  method 
of  testing  the  functional  capacity  of  the  kidney. 

Technic  of  Phloridzin  Test. — .005  gm.  of  phloridzin 
in  fresh  aqueous  solution  is  injected  hypodermically. 
At  15-minute  intervals  the  urine  collected  by  catheter  or 
voided  spontaneously  is  examined  for  sugar.  The 
maximum  excretion  takes  place  normally  in  an  hour 
and  disappears  in  2  or  3  hours. 

00  Centralbl.  f.  med.  Wissensch.,  1885,  531. 

31  Bull,  et  Mem.  Soc.  Med.  d.  Hop.  de  Paris,  1899,  379. 


108      Manual  of  Vital  Function  Testing  Methods 

3.     The  Hippuric  Acid  Test 

It  has  been  long  known  that  bcnzoic  acid  or  benzoates 
are  eliminated  by  the  kidney  as  hippuric  acid  which 
is  synthesized  in  the  kidney  from  benzoic  acid  and 
glycocoll.  Altho  the  fact  has  been  used  as  a  basis  for 
testing  kidney  function  the  results  have  been  disap- 
pointing and  the  method  lias  been  abandoned. 

4-     The  Lactose  Test 

Voit  32  was  the  first  to  demonstrate  that  lactose  is 
eliminated  by  the  healthy  kidney  following  its  sub- 
cutaneous or  intravenous  injection.  De  Bonis 33 
claimed  that  the  elimination  takes  place  exclusively  in 
the  glomerulus. 

Lactose  was  suggested  as  a  means  of  estimating  renal 
functions  in  1911  by  Schlayer  and  Takayasu,34  who 
with  their  co-workers  studied  the  question  of  renal  func- 
tion in  experimental  and  clinical  nephritis.  These 
workers  studied  the  elimination  of  lactose,  potassium 
iodide,  salt  and  water,  dividing  the  nephritides  into 
vascular  and  tubular  varieties  with  subdivisions. 

Schlayer  believed  that  the  elimination  of  lactose  be- 
ing exclusively,  as  he  thought,  a  glomerular  function 
could  be  taken  as  an  index  of  the  vascular  functioning 
power  of  the  kidney.  Lactose  being  a  foreign  sub- 
stance that  is  not  found  in  the  organism  would  not 
be  influenced  in  its  elimination  by  extrarenal  factors, 
and  should  therefore  be  an  ideal  criterion  of  glomerular 
function,  any  delay  in  its  passage  through  the  kidney 
indicating  glomerular  insufficiency. 

MDcut.  Arch.  f.  klin.  Med.,  1897,  LVII,  545. 
"Giorn.  intern,  cl.  scien.   Med.,   1907,  XXIX,  4iG. 
:"  Deutsch.  Arch.  f.  klin.  Med.,  1911. 


Tests  of  Kidney  Function  109 

Following  Nussbaum's  35  technic  of  obtaining  in  the 
frog  an  exclusively  tubular  secretion  from  the  kidney 
by  artificially  excluding  the  glomerular  secretion, 
Rowntree  and  Fitz  36  concluded  that  the  tubular  epithe- 
lium can  secrete  a  certain  amount  of  lactose,  hence  its 
elimination  is  not  exclusively  a  function  of  the  glomeru- 
lus.  But  they  concluded  also  from  their  clinical  experi- 
ments with  lactose  in  the  study  of  renal  function  in 
practice  and  also  from  some  studies  they  have  made 
in  experimental  passive  congestion,  that  the  mechanism 
of  lactose  excretion  differs  essentially  from  that  of 
phthalein,  salt,  indigo  carmin,  etc.,  and  that  estima- 
tions of  lactose  excretion  may  be  looked  upon  as  a 
satisfactory  index  of  the  vascular,  if  not  exclusively 
the  glomerular  function  of  the  kidney. 

Technic  of  Lactose  Test. — Two  and  five-tenths  (2.5) 
gms.  of  chemically  pure  lactose  are  dissolved  in  25  c.c. 
of  freshly  distilled  water,  placed  in  small  cotton  stop- 
pered Erlenmeyer  flasks  and  pasteurized  for  four 
hours  for  four  successive  days  at  75  to  80°  C.  By  this 
method  the  dose  injected  amounts  to  a  little  over  2 
gms.  lactose  in  20  c.c.  of  water.  A  fresh  solution  is 
used  for  each  injection  and  a  careful  technic  for  in- 
travenous injection  carried  out. 

Following  the  injection  there  are  usually  no  consti- 
tutional disturbances  altho  occasionally  there  may  be 
some  headache  malaise  or  even  chill  followed  by  fever. 

The  urine  is  collected  four  hours  after  the  injec- 
tion and  every  hour  or  two  hours  after  for  twelve 
hours.  Each  specimen  is  tested  for  sugar  by  Nylander's 
reagent,  using  the  same  amount  of  urine,  solution  and 
length  of  time  for  boiling.  Polarimetric  readings  may 
be  made. 

^Pfliiger's  Arch.  f.  d.  ges.  Physiol.,  1878,  XVI,  179;  XVII,  580. 
36  Archives  of  Int.  Med.,   1913,  XI,  258. 


110      Manual  of  Vital  Function  Testing  Methods 

The  normal  excretion  time  for  this  amount  of  lac- 
tose is  four  to  six  hours.  The  time  required  for  secre- 
tion is  the  main  point.  Over  six  hours  is  delayed  ex- 
cretion. 

(Nylander's  reagent  consists  of  Rochelle  salts,  4 
gins,  dissolved  in  100  c.c.  of  10%  NaOH  (sp.  gr. 
1015);  warm  and  saturate  with  bismuth  subnitrate 
(about  two  grams  are  necessary).  When  cool,  filter 
and  keep  in  a  dark  bottle.  The  solution  remains  perma- 
nent for  years.) 

B.  ELIMINATION  OF  DIFFERENT  COLORING  MATTERS  OR 
DYES  AS  A  MEASURE  OF  RENAL  FUNCTION.  URINARY 
CHROMOSCOPY 

There  are  three  of  these  tests  used  at  the  present 
time,  namely: 

1.  The  Methylene  Blue  Test. 

2.  The  Indigo  Carmin  Test. 

3.  The  Phenolsulphonphthalein  Test. 

Other  coloring  matters  such  as  rosanilin,  fuchsin, 
etc.,  have  been  suggested  and  employed  at  different 
times  for  estimating  renal  function,  but  with  the  ex- 
ception of  the  three  named  they  appear  to  have  fallen 
into  disuse  at  the  present  time. 

Numbers  2  and  3  are  most  extensively  employed, 
namely,  indigo  carmin  which  is  used  particularly  in 
Europe  and  phenolsulphonphthalein  which  is  by  far 
the  most  popular  colorimetric  test  in  this  country. 

Rosanilin  (sodium  trisulphate)  was  introduced  by 
Lepine.37  One  c.c.  of  a  \c/o  solution  is  injected  hypo- 
dcrmically.  The  dye  appears  normally  in  the  urine 
in  less  than  half  an  hour,  total  elimination  requiring 
twenty-four  hours.  The  test  has  never  attained  wide 
37  Lyon  Medical,  1898. 


Tests  of  Kidney  Function  111 

use,  probably  because  of  the  greater  success  attending 
the  use  of  phenolsulphonphthalein  according  to  the 
method  of  Rowntree  and  Geraghty  (q.  v.). 

1.     The  Meihylene  Blue  Test 

The  introduction  of  methylene  blue  as  a  test  for 
renal  function  is  credited  to  Achard  and  Castaigne.38 
These  authors  gave  the  drug  intramuscularly,  using 
1  c.c.  of  a  5  %  solution.  Later  Czyhlarz  and  Donoth  39 
recommended  it  by  mouth  in  1/4  grain  dose.  The  drug 
is  rapidly  eliminated  in  the  urine,  appearing  therein  in 
about  fifteen  minutes  as  a  colorless  chromogen,  as  dem- 
onstrated by  Voisin,40  which  may  be  shown  by  boiling 
the  urine  after  addition  of  acetic  acid.  Normally  the 
color  itself  appears  in  the  urine  in  half  an  hour.  The 
excretion  of  both  forms  continues  for  36-48  hours,  but 
even  in  health  the  time  may  be  very  much  prolonged. 

The  authors  of  the  test  recommended  that  the  time 
of  first  appearance,  time  of  maximum  intensity  of 
excretion  and  time  required  for  total  excretion  should 
be  noted. 

Diminished  renal  permeability  was  thought  to  delay 
or  prolong  all  three.  Various  observers  confirmed 
these  suppositions.  In  some  cases  of  chronic  inter- 
stitial nephritis  the  elimination  was  found  to  be  pro- 
longed for  two  weeks.  Various  modifications  of  the 
type  of  elimination  under  pathological  conditions  were 
described,  consisting  of  remittances  or  intermittances  of 
excretion. 

Later  observers  noted  that  elimination  is  not  delayed 
in  all  forms  of  kidney  disease  and  that  the  elimination 

38  Bull,  et  Mem.  Soc.  Med.  d.  hop.  de  Paris,  April,  1897,  63T. 
39Wien.  klin.  Wchnschr.,  XXIV,   1899,  649. 
40Gaz.  Hebd.  Med.,  1897,  493. 


Manual  of  Vital  Function  Testing  Methods 

under  certain  circumstances  might  be  normal  or  even 
accelerated. 

Attempts  to  measure  quantitatively  the  elimination 
of  methylene  blue  were  made,  one  of  which  described 
by  Rowntree  and  Geraghty  will  be  mentioned  under 
technic. 

The  methylene  blue  test  was  later  applied  to  diag- 
nosis in  surgical  diseases  of  the  genitourinary  tract 
and  was  at  one  time  considered  the  best  test  available 
for  estimating  the  functional  capacity  of  one  or  both 
kidneys.  Walker  showed  that  the  elimination  is  re- 
tarded in  lower  urinary  tract  obstructions  as  in  cer- 
tain types  of  prostatic  hypertrophy.  Casper  made 
similar  observations. 

Methylene  blue  produces  some  pain  when  given  sub- 
cutaneously  and  occasionally  when  given  intramuscu- 
larly. This  of  course  is  a  drawback  though  perhaps 
not  a  serious  one.  Another  and  greater  drawback  is  its 
prolonged  elimination  necessitating  a  large  number  of 
urine  examinations.  A  third  objection  is  the  difficulty 
of  accurate  colorimetric  estimations. 

Finally,  the  methylene  blue  test  is  imperfect  in  that 
part  of  the  substance  is  converted  into  a  colorless 
chromogen  in  the  body  secreted  as  a  leucobase  and 
therefore  does  not  contribute  to  the  color  results  in 
the  urine.  Only  50%  of  the  drug  is  normally  passed 
out  in  the  urine. 

It  has  not  been  demonstrated  with  certainty  in  what 
part  of  the  kidney  the  elimination  of  methylene  blue 
takes  place. 

In  disease  of  the  tubular  epithelium  that  is  in  the 
chronic  parenchymatous  nephritis,  methylene  blue  is 
quickly  and  completely  eliminated ;  in  interstitial  neph- 
ritis, the  elimination  is  delayed. 

The  duration  of  elimination  is  diminished  in  paren- 


Tests  of  Kidney  Function  113 

chymatous  and  increased  in  interstitial  nephritis.  A 
cyclic,  polycyclic  or  intermittent  elimination  of  the 
coloring  matter  has  been  said  to  indicate  several  dif- 
ferent conditions :  disturbance  of  kidney  innervation, 
hepatic  insufficiency,  interstitial  nephritis  and  pyo- 
hydronephrosis. 

Up  to  the  time  of  the  advent  of  the  phenolsul- 
phonphthalein  test,  the  methylene  blue  test  was  the 
most  extensively  used  method  of  determining  renal  per- 
meability. At  the  present  time,  certainly  in  America, 
the  Rowntree-Geraghty  test  has  quite  superseded  it. 

Teclinic  of  Methylene  Blue  Test.— After  urination 
1  c.c.  of  a  5%  solution  of  methylene  blue  is  injected 
intramuscularly.  A  sterile  catheter  may  be  introduced 
into  the  bladder  or  the  patient  may  empty  the  bladder 
in  15  minutes  if  possible  to  determine  the  presence  of 
the  leucobase  or  chromogen.  This  is  done  by  boiling 
the  specimen  and  adding  a  few  drops  of  acetic  acid. 
A  greenish  color  denotes  the  presence  of  the  chromogen. 
At  the  end  of  half  an  hour  the  bladder  should  be 
emptied  spontaneously  or  by  catheter  and  the  urine 
examined  for  color.  A  greenish  blue  color  denotes  the 
presence  of  the  dye. 

As  above  mentioned,  the  time  of  appearance,  time  of 
maximum  intensity  and  time  required  for  total  elimina- 
tion (disappearance  of  color)  should  be  noted. 

Quantitative  Estimation. — Before  administration  of 
the  drug  the  urine  is  collected  for  some  time  and  kept. 
The  methylene  blue  is  given  in  the  usual  manner,  the 
urine  collected  for  as  long  a  time  as  necessary,  all 
chromogen  being  converted  into  dye.  An  equal  quan- 
tity of  urine  previously  collected  is  taken,  to  which 
is  added  from  a  burette,  drop  by  drop,  a  sufficient 
quantity  of  a  solution  of  methylene  blue  of  known 
strength  until  the  colors  are  alike.  Compare  against 


114      Manual  of  Vital  Function  Testing  Methods 

a  white  background.  From  the  quantity  of  methylenc 
blue  used,  the  amount  of  coloring  matter  may  be  esti- 
mated. 

2.     The  Indigo  Carmm  Test — Volcker- Joseph  Test 41 

The  dye  was  first  used  by  Heidenhain  in  his  famous 
investigations  into  the  physiology  of  the  kidney.  He 
believed  that  this  substance  is  eliminated  exclusively 
by  the  epithelial  cells  of  the  convoluted  tubules. 

Indigo  carmin  possesses  the  advantages  over  methy- 
lene  blue  that  the  quantity  required  for  the  test  is 
completely  eliminated  thro  the  kidney  and  that  no 
leucoderivative  is  formed  in  the  tissues. 

After  the  intramuscular  injection  of  .08  gm.  to  .16 
gm.  of  indigo  carmin,  elimination  begins  in  6  to  8  min- 
utes if  the  kidney  is  normal.  The  intensity  of  the  color 
will  give  some  idea  of  the  concentrating  power  of  the 
kidney,  that  is  to  say,  the  water  resorbing  power  of 
the  tubules,  and  consequently,  its  capacity  to  produce 
a  urine  of  high  molecular  concentration. 

A  polycyclic  or  intermittent  elimination  is  said  by 
Blum  to  indicate  intermittent  hydronephrosis.  In 
strongly  alkaline  urine  the  dye  may  be  discolorized. 
In  parenchymatous  nephritis,  the  elimination  of  indigo 
carmin  may  be  normal.  In  interstitial  nephritis  the 
elimination  begins  later  than  normal,  is  diminished  in 
quantity  and  much  prolonged.  The  delayed  elimination 
indicates  a  diminished  reaction  power  of  the  kidney,  the 
diminished  elimination  a  loss  of  water  resorbing  power, 
a  hyposthenuria,  a  loss  of  the  concentrating  function 
of  the  organ,  while  the  long  duration  of  elimination  indi- 
cates a  general  loss  of  secreting  power  as  always  accom- 
panies the  sclerotic  kidney. 

"Munch,  med.  Wchnschr.,  1903,  2081. 


Tests  of  Kidney  Function  115 

The  indigo  carmin  test  has  been  quite  extensively 
used,  especially  in  Europe,  in  testing  the  functional 
capacity  of  the  single  kidney  by  ureteral  catheteriza- 
tion  and  in  general  functional  testing  of  the  kidney.  It 
is  considered  superior  to  methylene  blue  because  of 
more  rapid  elimination.  But  in  this  respect,  as  in 
others,  it  is  inferior  to  phenolsulphonephthalein,  which 
substance,  since  its  introduction  for  this  purpose  by 
Rowntree  and  Geraghty,  has  become  the  most  exten- 
sively used  chromoscopic  test,  at  least  in  this  country. 

Rowntree  and  Geraghty  consider  the  indigo  carmin 
test  of  more  value  than  the  methylene  blue  test  because 
of  its  more  rapid  appearance  in  the  urine,  but  that  it 
is  less  adapted  to  functional  work  than  phenolsul- 
phonephthalein. This  opinion  is  now  shared  by  most 
other  workers  in  this  field. 

Technic  of  Indigo  Carmin  Test. — A  4%  solution  is 
made.  Twenty  c.c.  of  this  solution  are  injected  into  the 
muscles  usually  of  the  gluteal  region.  There  is  some 
pain  produced  by  the  injection.  In  10  to  15  minutes 
the  urine  is  collected.  In  normal  persons  it  is  tinged 
greenish  blue  in  this  time.  Excretion  is  usually  com- 
plete in  24  hours,  but  practically  the  greater  portion 
escapes  in  12  hours.  The  color  of  the  dye  in  the  urine 
does  not  lend  itself  well  to  colorimetric  estimation.  In 
this  respect  it  resembles  methylene  blue.  Purulent 
urine  decolorizes  indigo  carmin.  It  is  estimated  that 
not  more  than  25%  of  the  amount  injected  finds  its 
way  out  thro  the  kidneys.  The  fate  of  the  balance  is 
unknown. 

3.     The  Phenolsulphonephthalein  Test.    Rowntree- 
Ger eighty  Test  (The  Red  Test} 

The  phenolsulphonephthalein  test  of  kidney  function 
had  its  origin  in  the  pharmacological  researches  of 


116      Manual  of  Vital  Function  Testing  Methods 

Abel  and  Rowntree,  upon  the  phthaleins  generally.  Of 
all  the  phthaleins  studied  by  these  investigators,  phe- 
nolsulphonephthalein  stood  out  in  striking  contrast 
with  all  others  because  of  the  fact  that  it  is  almost  ex- 
clusively eliminated  by  the  kidney. 

This  fact  suggested  its  use  as  a  test  of  renal  func- 
tion to  Rowntree  and  Geraghty  and  their  first  com- 
munication upon  this  subject  appeared  in  July,  1910.42 

Phenolsulphonephthalein  has  the  following  formula: 

'CfiILOH 


CGH4OH 


C6H4 


It  was  first  made  by  Remsen.43  The  substance  is  a 
red  crystalline  powder,  partly  soluble  in  water,  the 
solution  when  alkaline  being  red,  becoming  more  purple 
as  the  alkalinity  is  increased. 

Abel  and  Rowntree  in  their  pharmacological  inves- 
tigations of  the  phthalein  group  showed  that  the  sub- 
stance appears  in  the  urine  after  administration  by 
mouth  in  one  to  one  and  a  half  hours  and  after  sub- 
cutaneous injection  in  about  10  minutes.  They  found 
that  after  fair-sized  doses  (1  gm.)  the  drug  appears 
in  the  bile,  is  passed  into  the  intestine,  there  reabsorbed, 
and,  except  for  a  mere  trace,  is  excreted  wholly  by  the 
urine. 

Phenolsulphonephthalein     is     practically     non-toxic. 

43  Jour.  Pharmacol.  and  Exp.  Therap.,  I,  1910,  579. 
"Amer.  Chem.  Jour.,  VI,  280. 


Tests  of  Kidney  Function  117 

When  a  dose  of  .006  gm.  is  injected  subcutaneously, 
40-60%  of  this  quantity  is  recovered  in  the  urine  dur- 
ing the  first  hour  after  injection.  From  15-25%  more 
is  recovered  in  the  second  hour,  making  a  total  excretion 
for  the  first  two  hours  following  the  injection  of 
60-85%. 

Normally  when  the  urinary  flow  is  free,  the  dye  ap- 
pears in  the  urine  in  5  to  10  minutes  after  injection. 
The  maximum  excretion  appears  in  15  to  20  minutes. 
This  density  of  excretion  continues  an  hour  to  an  hour 
and  a  half.  The  elimination  then  begins  to  diminish. 
At  the  end  of  the  first  hour  the  pink  color  on  addition 
of  alkali  is  slight,  and  after  the  expiration  of  two  hours 
excretion  is  practically  complete. 

In  acute  nephritis,  Rowntree  and  Geraghty  44  found 
a  diminished  excretion  of  phthalein  in  two  out  of  three 
cases.  In  parenchymatous  nephritis  there  was  a  marked 
diminution  of  excretion  in  seven  out  of  eight  cases.  In 
chronic  interstitial  nephritis  a  low  output  was  encoun- 
tered in  all  the  cases  experimented  upon,  10  in  number. 

These  results  concerning  the  lowered  excretion  of 
phenolsulphonephthalein  in  the  nephritides  have  as  a 
general  thing  been  entirely  corroborated  in  subsequent 
investigations  by  many  different  observers. 

In  their  first  researches  Rowntree  and  Geraghty 
made  over  two  hundred  functional  tests  in  one  hundred 
and  fifty  persons.  To  them  the  phenolsulphonephtha- 
lein seemed  to  possess  advantages  over  all  other  func- 
tional tests,  these  advantages  consisting  chiefly  in  the 
following  points: 

1.  The  early  appearance   of  the  dye  in  the   urine 
and  its  rapid  and  complete  elimination  by  the  kidney. 

2.  The  accuracy  and  simplicity  of  quantitative  esti- 
mation of  the  drug  in  the  urine. 

"Jour.  Phar.  and  Exp.  Ther.,  I,  1910,  656. 


118      Manual  of  Vital  Function  Testing  Methods 

They  showed  by  these  researches  that  the  permeabil- 
ity of  the  kidney  for  phenolsulphonephthalein  is  de- 
creased in  both  parenchymatous  and  interstitial  nephri- 
tis, the  decrease  being  most  marked  in  the  latter  form. 

Further  than  this  they  showed  that  the  test  is  of 
value  to  the  surgeon  in  determining  the  true  condition 
of  the  kidney,  in  cases  with  prostatic  obstruction.  In 
such  cases  the  authors  believed  the  phenolsulphoneph- 
thalein test  to  be  of  greater  service  than  urinalysis  or 
nitrogen  estimations  and  that  the  use  of  the  test  in 
cases  of  obstruction  in  the  lower  urinary  tract  prior 
to  operations  would  disclose  the  necessity  of  prelimi- 
nary treatment.  Finally  they  pointed  out  that  the 
test  lends  itself  and  is  well  adapted  to  unilateral  esti- 
mations of  the  functions  of  the  separate  organs  in  con- 
junction with  ureteral  catheterization. 

In  surgical  cases  with  urinary  obstruction,  the 
authors  contended  that  when  the  phthalein  excretion 
is  delayed  beyond  twenty-five  minutes  and  the  output 
for  the  first  hour  is  below  20%  the  operation  may  prof- 
itably be  postponed  until  treatment  by  drainage  has 
improved  conditions,  such  improvement  being  shown  by 
an  increase  in  the  elimination  of  phthalein  at  a  subse- 
quent time. 

Technic  of  Phenolsulphonephthalein  Test. — Twenty 
minutes  to  half  an  hour  before  giving  the  test  the 
patient  is  given  200  to  400  c.c.  of  water  to  insure 
diuresis.  The  bladder  is  cathetcrized  or  completely 
emptied.  The  time  being  noted,  1  c.c.  of  a  solution  of 
the  drug  is  injected  into  the  lumbar  muscles.  The  solu- 
tion is  prepared  as  follows :  .6  gm.  phenolsulphoneph- 

2 

thalein  and  .84  c.c.    -     NaOH  are  added  to  .75%  NaCl 
n 

2 

solution.     Add  two  or  three  drops  of         NaOH.     The 

n 


Tests  of  Kidney  Function  119 

color  becomes  Bordeaux  red  and  the  solution  is  non- 
irritant. 

The  urine  is  passed  into  a  test  tube  containing  a  drop 
of  25  %  NaOH  and  the  time  of  appearance  of  the  first 
pinkish  color  noted. 

If  there  is  no  urinary  obstruction  the  catheter  is 
not  necessary  after  the  appearance  of  the  color,  and 
the  patient  may  then  retain  the  urine  and  urinate  at 
the  end  of  one  hour  in  one  receptacle  and  again  at  the 
end  of  the  second  hour  in  another. 

A  rough  estimate  of  the  time  of  the  appearance  of 
the  drug  in  the  urine  may  be  gained  by  having  the 
patient  urinate,  frequently,  a  small  amount  without 
the  catheter.  In  prostate  cases  it  seems  better  to  keep 
a  catheter  in  situ.  If  this  is  done  the  catheter  may 
be  corked  and  this  is  removed  at  the  end  of  the  first 
and  second  hours. 

Each  sample  of  urine  is  measured.  Twenty-five  per 
cent.  sol.  NaOH  is  added  to  make  the  color  maximum. 
The  urine  is  usually  yellow  or  orange  and  becomes  deep 
purple  on  addition  of  the  alkali.  The  solution  is  put  in 
a  liter  flask  and  diluted  with  distilled  water  to  make  a 
quart.  This  is  thoroughly  mixed  and  a  portion  is  fil- 
tered and  compared  with  a  standard  in  a  colorimeter.45 
The  standard  solution  consists  of  .003  gm.  phenolsul- 
phonephthalein  (^  c.c.  of  solution  used  for  injection) 
diluted  to  1  liter  and  made  alkaline  with  a  few  drops 
of  25%  NaOH.  The  test  solution  retains  its  fine 
purplish  color  for  a  week  or  more. 

The  colorimeter  contains  a  wedge-shaped  cup  which 
is  filled  with  the  standard  solution.  The  rectangular 

45  The  colorimeter  used  by  Rowntree  and  Geraghty  is  a  modi- 
fication of  the  Autenrieth-Konigsberger  instrument.  This  can  be 
obtained  from  Hynson  and  Westcott,  Balto.,  Md.,  who  also  sup- 
ply convenient  ampoules  containing  .006  gm.  in  each  c.c.  of  phe- 
nolsulphonphthalein. 


120      Manual  of  Vital  Function  Testing  Methods 

cup  is  filled  with  the  solution  to  be  tested.  The  wedge- 
shaped  cup  is  manipulated  by  a  screw  until  the  color 
fields  are  identical.  The  percentage  is  read  off  on  the 
indicator  scale. 

Technic  of  the  Phenolsulphonephthalein  Test  as  Ap- 
plied to  Estimation  of  the  Function  of  the  Individual 
Kidney. — Twenty  minutes  previous  to  the  application 
of  the  test  the  patient  is  given  600  to  800  c.c.  of  water 
to  provide  a  free  flow  of  urine.  The  ureters  are 
catheterized,  a  special  catheter  being  recommended, 
namely,  the  flute  end  catheter  of  Albarran  No.  6  or 
No.  7.  The  catheters  are  passed  four  inches  into  the 
ureters.  The  cystoscope  is  withdrawn,  leaving  the 
catheters  in  situ.  A  small  urethral  catheter  is  passed 
into  the  bladder  to  empty  that  organ  and  detect  later 
leakage.  The  other  details  of  the  test  are  similar  to 
those  of  the  ordinary  technic  (q.  v. ). 

In  September,  1911,  Geraghty  and  Rowntree  46  made 
a  report  of  their  previous  experience  with  the  sul- 
phonephthalein  test  and  reiterated  their  first  opinion 
that  the  test  devised  by  them  appeared  to  possess  dis- 
tinct advantages  over  all  other  methods  of  examining 
renal  function.  The  reasons  upon  which  this  opinion 
was  based  have  been  given  above. 

They  concluded  that  the  sulphonephthalein  test  will 
enable  the  clinician  to  determine  quantitatively  the 
amount  of  functional  derangement  of  the  kidneys  in 
his  nephritis  cases,  whether  of  the  acute  or  chronic 
type.  That  in  cardiorenal  cases  the  test  will  show 
exactly  to  what  extent  the  kidney  is  involved.  That 
the  test  is  of  special  value  in  the  diagnosis  of  uremia 
from  other  conditions  which  may  simulate  it  and  also 
to  foretell  in  many  cases  an  impending  uremia  before 
the  appearance  of  indubitable  clinical  signs. 
46  Jour.  Arner.  Med.  Assn.,  1911,  LVII,  815. 


Tests  of  Kidney  Function 

The  authors  reiterated  their  confidence  in  the  value 
of  this  test  in  cases  of  urinary  obstruction,  it  being 
in  their  judgment  superior  under  these  circumstances 
to  measuring  the  urinary  quantity,  and  to  urea  or  total 
nitrogen  estimations. 

In  many  surgical  cases  studied  by  them  in  the  genito- 
urinary clinic  of  Young  at  Johns  Hopkins,  they  found 
that  separate  studies  of  unilateral  kidney  function  re- 
vealed more  accurate  and  dependable  information  than 
any  other  method  of  examination. 

In  a  third  and  very  complete  report  of  their  phenol- 
sulphonephthalein  test  of  kidney  function  published  in 
1912,  Rowntree  and  Geraghty  studied  carefully  the  in- 
fluence on  the  rate  of  excretion,  of  the  various  methods 
of  administration,  subcutaneous,  intramuscular  and  in- 
travenous. They  concluded  from  their  researches  that 
intramuscular  injection  into  the  lumbar  region  is  the 
method  of  choice. 

Studying  the  influence  of  various  diuretics  upon  the 
excretion  of  sulphonephthalein  the  authors  found  that 
while  under  the  conditions  of  animal  experimentation, 
some  slight  increased  activity  was  caused  by  certain 
stimulating  diuretics  like  caffein,  yet  clinically  these 
substances  do  not  affect  the  phthalein  output. 

The  route  of  phthalein  through  the  kidney  was  in- 
vestigated and  it  was  demonstrated  that  the  drug  is 
excreted  chiefly  by  the  uriniferous  tubules  and  the 
smaller  remainder  by  the  glomerulus. 

In  nephritis  of  all  types  the  output  of  phthalein 
was  found  diminished,  the  diminution  of  excretion  be- 
ing apparently  in  proportion  to  the  amount  of  damage 
to  the  kidney  structure.  So  that  the  test  is  of  consider- 
able value  from  a  diagnostic  and  prognostic  standpoint 
since  the  amount  of  functional  incapacity  is  revealed. 

In  those  cases  in  which  the  heart   and  kidney  are 


Manual  of  Vital  Function  Testing  Methods 

both  affected  (the  so-called  cardiorenal  cases)  the  test 
was  found  useful  in  determining  just  what  proportion 
of  the  trouble  could  be  referred  to  the  heart  disease  and 
what  to  the  renal  lesions. 

In  uremia  the  test  proved  in  the  hands  of  its  authors 
of  value  in  differentiating  uremia  from  conditions  sim- 
ulating it.  In  certain  cases,  when  no  clinical  evidence 
of  the  imminence  of  uremia  was  present,  a  very  low 
phthalein  output  frequently  enabled  the  authors  to  fore- 
see the  danger. 

From  a  surgical  standpoint  the  earlier  opinions  held 
by  Rowntree  and  Geraghty  as  to  the  utility  of  the  test 
in  cases  of  urinary  obstruction  were  completely  cor- 
roborated by  their  subsequent  work. 

According  to  them  the  test  is  more  dependable  than 
estimation  of  urinary  output,  total  solids,  urea  or  total 
nitrogen,  in  indicating  to  the  surgeon  the  propriety  of 
operation  or  the  institution  of  preliminary  treatment, 
in  contemplated  nephrectomy  and  prostatectomy. 

Finally  their  studies  tended  to  show  that  no  other 
test  is  so  adaptable  to  the  examination  of  unilateral 
kidney  function  to  determine  the  relative  amount  of 
work  performed  by  each  organ  separately. 

The  medical  and  surgical  aspects  of  the  phthalein 
test  will  be  further  developed  later  on  under  the  general 
summary  of  renal  function  tests  in  their  medical  and 
surgical  aspects,  (v.i. ) 

Since  the  introduction  of  the  phenolsulphonephtha- 
lein  test  for  kidney  function  in  July,  1910,  a  very  con- 
siderable literature  upon  the  subject  has  appeared.  It 
is  very  striking  how  few  are  the  criticisms  and  how 
numerous  are  the  encomiums  which  have  been  passed 
upon  the  test  of  Rowntree  and  Geraghty.  It  might  al- 
most be  said  that,  in  this  country  at  least,  the  opinion 
of  those  who  have  used  it  is  unanimously  favorable  and 


Tests  of  Kidney  Function  123 

tends  to  corroborate  in  every  particular  the  claims 
which  were  advanced  for  it  by  its  authors. 

Clinical  and  experimental  corroboration  of  the  sul- 
phonphthalein  test  have  been  given  by  the  publications 
of  Austin  and  Eisenbrey,47  Boyd,48  Cooke,49  Sehrt,50 
Lance,51  Sanford,52  Behrenroth,53  Frank,53  Bonn,54 
Erne,55  Mouriquand,56  Lohnstein,57  Frothingham, 
Fitz,  Folin,  Denis,58  Christian,  Janeway,  Cabot, 
Dock,59  Snowden,  Thayer,59a  and  many  others. 

While  many  of  these  reports  are  extremely  illuminat- 
ing and  important,  it  cannot  be  said  that  they  have 
added  anything  noteworthy  to  the  test  itself,  or  to  its 
indications,  which  fact  is  a  strong  testimony  of  the  thor- 
oughness and  care  with  which  the  work  had  originally 
been  performed  by  Rowntree  and  Geraghty  before  its 
publication. 

From  the  standpoint  of  pure  experimental  corrobora- 
tion, the  work  of  Austin  and  Eisenbrey  should  be  noted. 
These  authors  in  1911  studied  the  elimination  of  phe- 
nolsulphonephthalein  as  compared  with  the  elimination 
of  nitrogen  and  chlorides,  in  experimental  nephritis  in 
dogs  set  up  by  administering  uranium,  cantharidin,  and 
potassium  bichromate.  They  concluded,  among  other 

"Jour.  Exper.  Med.,  1911,  XIV,  367;  4,62. 

48  Jour.  Amer.  Med.  Assn.,  1912,  LVIII,  620. 

49  Providence  Med.  Jour.,   1912,   XIII,   118. 
80  Centralbl.  f.  Ch.,  1912,  XXXIX,  2,  1121. 

51  Gaz.  d.  hop.  de  Par.,  1912,  LXXXV,  32. 
62  Cleveland   Med.  Jour.,   1912,  XI,  763. 

53  Ztsch.  f.  Exp.  Pathol.  u.  Therap.,  1913,  XIII,  72. 

54  Jour.  Ind.  State  Med.  Assn.,  1913,  VI,  154. 
"Munch,  med.  Wchnschr.,  1913,  LX,  510. 
5SLyon  Medicale,  1913,  CXXL,  299. 

"Allg.  Med.  Centr.  Gtz.,  1913,  LXXXII,  591. 

58  Arch.  Int.  Med.,  1913,  vols.  XI-XII;  also  Jour.   Exper.  Med., 
1911,  XIV,  366. 

59  Tr.  Cong.  Amer.  Phys.  &  Surg.,  1913,  IX,  45. 
69aAmer.  Journ.   Med.   Sc.,   1914,  CXLVIII,   781. 


Manual  of  Vital  Function  Testing  Methods 

things,  as  a  result  of  their  researches,  that  a  marked 
and  early  decrease  in  the  elimination  of  phenolsulpho- 
nephthalein  takes  place  in  the  experimental  nephritides 
and  that  the  phthalein  test  is  the  better  indicator  of 
renal  function  under  the  circumstances  than  total  ni- 
trogen or  chloride  elimination,  which  latter  are  more 
irregular  and  inconstant. 

Other  investigators  have  experimented  along  the  same 
line,  studying  the  phthalein  elimination  in  experimental 
nephritis  and  their  results  have  tended  to  corroborate 
the  earlier  researches.  Perhaps  the  most  recent  con- 
tribution to  this  phase  of  the  subject  is  that  of  Potter 
and  Bell.60  These  authors  have  studied  the  phthalein 
elimination,  also  that  of  lactose  and  potassium  iodide 
in  experimental  tartrate  nephritis  in  rabbits. 

It  may  be  recalled  that  Underbill,  Wells  and  Gold- 
schmidt  G1  discovered  that  the  injection  of  racemic  tar- 
taric  acid  into  rabbits  produces  a  type  of  acute  nephri- 
tis in  which  the  great  majority  of  the  convoluting  tu- 
bules become  necrotic  and  the  rest  are  fatty  and  gran- 
ular. The  glomeruli  may  be  anatomically  intact.  In 
kidneys  of  this  type  it  has  been  found  that  the  excretion 
of  phenolsulphonephthalein,  likewise  indigo  carmin  and 
methylene  blue,  is  completely  suppressed.  The  excre- 
tion time  of  lactose  is  over  twice  as  long  as  normal, 
while  that  of  potassium  iodide  is  four  times  as  long  as 
normal,  but  both  lactose  and  potassium  iodide  are  ex- 
creted by  this  type  of  kidney.  Potter  and  Bell  suggest 
that  their  results  appear  to  show  that  phthalein,  indigo 
carmin  and  methylene  blue  are  excreted  exclusively  by 
the  tubules,  while  potassium  iodide  and  lactose  are 
at  least  partly  excreted  by  the  glomeruli. 

In   experimental   chronic   passive   congestion    of  the 

°°Amer.  Jour.  Med.  Sci.,  CXLIX,  1915,  236. 
91  Jour.  Exper.  Mcd.,  1913,  XVIII,  322. 


Tests  of  Kidney  Function  125 

kidney  in  animals,  produced  by  compression  of  the  vena 
cava  and  renal  veins,  Rowntree,  Fitz,  and  Geraghty  62 
found  that  the  functional  capacity  of  the  kidney  as 
judged  by  the  phthalein  output  is  reduced.  The  reduc- 
tion, however,  only  occurs  as  the  degree  of  passive 
congestion  becomes  marked. 

Goldsborough  and  Ainley  in  1910  63  studied  the  renal 
function  in  pregnancy  and  the  puerperium  by  means  of 
sulphonephthalein,  and  concluded  that  even  normal  fe- 
males in  pregnancy  eliminate  less  phthalein  than  non- 
pregnant.  In  the  ninth  month  the  power  of  elimination 
may  be  very  low.  The  exact  meaning  of  these  facts  is 
not  known.  This  result  was  confirmed  by  Roth,64 
who  also  claimed  that  women  with  diseases  of  the  genital 
tract  were  unsuitable  for  the  test.  These  investigations 
of  Goldsborough,  Ainley  and  Roth  have  not  been  subse- 
quently developed.  In  this  connection  it  may  be  men- 
tioned that  Pepper  and  Austin  65  reported  in  1913  that 
occasionally  cases  of  parenchymatous  nephritis  will 
show  a  quite  prompt  and  fairly  normal  elimination  of 
phthalein.  In  one  of  their  cases  there  was  a  phthalein 
output  of  67%  for  one  hour,  strongly  suggesting 
hyperpermeability.  Baetjer  has  also  encountered  sim- 
ilar cases.  Such  cases  do  not  appear  to  represent  the 
rule,  however,  and  just  what  meaning  is  to  be  attached 
to  these  facts  is  at  present  unexplained. 

A  few  suggestions  for  slight  variations  of  technic  in 
the  test  have  been  published  but  none  of  them  appears 
to  have  been  generally  adopted.  They  are  few  in  num- 
ber and  the  most  important  may  be  given. 

Fromme  and  Rubncr  GG  in  1912  suggested  that  the 

82  Arch,  of  Int.  Med.,  1913,  XI,  121. 

""Journ.  Amer.   Med.   Assn.,   1910,  LV,  2058. 

64Berl.  klin.  Wchnschr.,  1913,  L,  1609. 

65  Amer.  Journ.  Med.  Sc.,  1913  n.  s.  CXLV,  254. 

66Berl.  klin.   Wchnschr.,   1912,  XLIX,  1889. 


126      Manual  of  Vital  Function  Testing  Methods 

phthalein  should  always  be  given  hypodermically  and 
that  the  observation  period  should  be  extended  to  three 
hours.  Keyes  and  Stevens  67  also  recommend  hypoder- 
mic injection  when  the  ureters  are  to  be  catheterized. 
Bonn,68  as  a  result  of  his  experience,  thought  that  the 
time  of  appearance  of  the  dye  in  the  urine  is  not  of 
much  importance  except  to  determine  the  time  for  per- 
centage estimation.  He  recommended  the  intravenous 
injection  of  the  phthalein  when  the  ureters  are  to  be 
catheterized.  He  does  not  believe  that  the  test  will 
inform  the  surgeon  when  the  patient  can  be  operated  on 
safely.  He,  however,  states  that,  in  his  belief,  the  test 
is  the  best  one  yet  devised  for  studying  the  renal  func- 
tion. 

Fanz  69  suggests  to  add  a  quantity  of  the  patient's 
urine  obtained  just  before  injecting  the  indicator,  equal 
in  amount  to  the  first  hour's  urinary  output  after  the 
injection.  The  standard  solution  now  will  have  ap- 
proximately the  same  amount  of  urinary  salts  as  the 
specimen  solution,  and  the  standard  and  urinary  solu- 
tion will  equal  each  other  in  opaqueness  and  yellowish 
tint,  making  color  comparison  easy.  To  make  up  the 
standard  solution,  he  uses  1  c.c.  of  the  contents  of  an 
ampoule  *  of  the  phcnolsulphonephthalein,  adds  the  pa- 
tient's urine  (obtained  before  injecting  the  indicator) 
in  amount  to  equal  the  first  hour's  urinary  output  after 
appearance  of  the  drug.  This  mixture  is  alkalinizcd 
with  25  c.c.  of  10 %  solution  of  potassium  hydroxide, 
filtered,  and  sufficient  distilled  water  is  added  to  make 
1000  c.c.  This  is  the  standard  and  contains  100%  of 
the  indicator  in  1000  c.c. 

67  N.  Y.  Meet  Jour.,  1912,  XCV,  1134. 

88  Indiana  State  Med.  Assn.  Jour.,  1913,  VI,  154. 

68  N.  Y.  Med.  Jour.,  1915,  C,  1193. 

*  Put  on  market  by  Hynson  and  Westcott. 


Tests  of  Kidney  Function  127 

The  first  hour's  urinary  output,  after  injection  of 
2  c.c.  phenolsulphonephthalein,  is  now  alkalinized  with 
25  c.c.  of  10%  potassium  hydroxide  and  filtered.  To 
this  is  added  distilled  water  to  make  1000  c.c.  This  is 
the  test  specimen.  By  diluting  a  unit  of  the  standard, 
say  50-100  or  200  c.c.,  with  distilled  water  until  it 
matches  the  1000  c.c.  solution  of  the  first  hour's  urinary 
output,  the  direct  percentage  of  the  indicator  in  the 
first  hour's  specimen  can  easily  be  estimated.  Say  100 
c.c.  of  the  standard  had  to  be  diluted  up  to  500  c.c. 
before  it  matched  the  first  hour's  specimen  dilution,  then 
the  standard  would  be  five  times  as  strong  as  the  speci- 
men, or  the  specimen  would  contain  20%  of  phenolsul- 
phonephthalein. The  second  hour's  output  of  phenol- 
sulphonephthalein is  estimated  precisely  like  the  first. 

As  a  matter  of  fact  it  does  not  appear  that  any 
modifications  of  the  original  test  method  as  described 
by  Rowntree  and  Geraghty  has  contributed  materially 
to  its  simplification  or  improvement,  and  for  this  reason 
the  original  method  is  usually  followed. 

Thayer  and  Snowden  70  have  recently  attempted  to 
compare  their  results  obtained  by  the  test  with  the 
anatomical  changes  found  in  the  kidneys  at  autopsy. 
They  conclude,  as  the  result  of  their  quite  extensive 
investigations,  as  follows : 

In  severe  chronic  nephritis  there  is  always  a  low 
phthalein  output.  This  rule,  in  their  experience,  has 
absolutely  no  exception.  The  phthalein  output  in  cases 
of  chronic  nephritis  diminishes  steadily,  according  to 
them,  until  the  terminal  uremia,  when  it  approaches 
zero,  just  prior  to  death. 

In  the  passive  renal  congestion  of  heart  disease,  there 
is  often  a  reduction  in  the  elimination  of  phthalein, 
especially  when  the  amount  of  decompensation  of  the 

70Amer.  Jour.  Med.  Sci.,  1914,  CXLVIII,  781. 


128      Manual  of  Vital  Function  Testing  Methods 

heart  is  considerable.  When  these  symptoms  become 
ameliorated,  the  phthalein  output  increases. 

If  passive  congestion  of  the  kidney  from  heart  disease 
is  accompanied  by  concomitant  chronic  nephritis  the 
output  of  phthalein  is  lower  than  in  cases  of  uncom- 
plicated congestion. 

In  one  case  of  acute  nephritis  and  one  of  amylosis 
the  phthalein  output  was  reduced. 

In  acute  infectious  diseases,  during  which  cloudy 
swelling  of  the  renal  parenchyma  occurred,  there  was 
found  a  considerable  reduction  of  phthalein  output. 

From  this  study  Thayer  and  Snowden  concluded 
that  the  phenolsulphonephthalein  test  of  Rowntree  and 
Geraghty  is  a  procedure  of  great  diagnostic  and  prog- 
nostic value,  especially  in  the  study  of  chronic  neph- 
ritis. 

General  Summary  of  the  Application  of  Renal  Func- 
tion Tests 

This  subject  may  be  divided  into  two  parts :  1.  Renal 
Function  Tests  and  Their  Medical  Application.  2. 
Renal  Function  Tests  and  Their  Use  in  Surgery. 

1.  Medical  Application. — A  decade  ago  the  burning 
question  in  renal  pathology  was  whether  the  varying 
clinical  findings  in  chronic  nephritis  could  be  divided 
into  classes  and  each  class  correlated  with  certain  defi- 
nite histopathological  findings  in  a  kidney  post  mortem. 
Although  no  absolute  answer  to  the  question  was 
reached,  there  is  no  doubt  some  progress  was  made. 
During  the  past  decade,  in  line  with  the  general  depar- 
ture of  interest  somewhat  away  from  the  anatomical 
toward  the  functional  view  in  pathology,  a  serious  at- 
tempt was  made  to  divide  the  clinical  symptomatology 
of  nephritis  into  groups ;  to  correlate  these  groups  with 


Tests  of  Kidney  Function  129 

certain  definite  types  of  renal  involvement.  Although 
this  worthy  attempt  has  not  been  entirely  successful  any 
more  than  its  anatomical  prototype  which  preceded  it, 
some  important  facts  have  been  learned  which  are  of 
value  from  a  practical  as  well  as  a  theoretical  stand- 
point. The  method  by  which  these  advances  have  been 
gained  is  none  other  than  the  application  of  functional 
tests  to  a  study  of  the  different  phases  of  renal  activity. 

Different  portions  of  the  glomerulo-tubular  structure 
of  the  kidney  have  been  supposed  to  possess  selective 
secretory  activities.  It  cannot  be  said  that  these  selec- 
tive activities  are  yet  understood,  so  that  at  the  present 
time  there  is  no  such  thing  as  an  exact  topical  diagnosis 
of  the  kidney  functions. 

Nor  can  it  be  said  in  any  case  that  the  results  of  the 
most  complete  and  comprehensive  functional  examina- 
tion will  reveal  with  any  certainty  the  anatomical 
changes  which  are  present  in  the  kidney.  Certainly 
they  will  not  reveal  the  extent  to  which  the  vascular, 
glomerular  or  tubular  structures  are  involved  in  a  given 
case,  and  will  shed  but  little  light  upon  the  relative 
proportions  of  the  changes. 

Our  chief  clinical  terms  in  renal  pathology  still  re- 
main as  they  were  in  the  older  tradition ;  we  still  speak 
currently  of  acute  nephritis,  chronic  parenchymatous 
nephritis  and  chronic  interstitial  nephritis,  but  we  are 
not  surprised  when  the  autopsy  shows  the  extreme  rar- 
ity of  these  arbitrary  types  and  presents  us  with  patho- 
logical pictures  of  such  great  complexity  that  it  is  no 
wonder  that  the  intricate  problem  is  not  to  be  solved  by 
the  most  skillful  and  painstaking  ante-mortem  exami- 
nation. 

Great  hopes  were  aroused  some  years  ago  in  this 
direction  when  it  was  discovered  that  experimental  in- 
flammation of  the  kidney  may  be  set  up  in  animals  by 


130      Manual  of  Vital  Function  Testing  Methods 

the  use  of  certain  poisons  71  which  make  it  possible  to 
submit  some  of  these  difficult  problems  in  renal  pathol- 
ogy to  experimental  investigation.  Although  little  has 
come  of  this  work  so  far,  it  appears  to  be  founded 
upon  rational  and  scientific  principles  and  the  work 
must  be  enthusiastically  encouraged  to  go  on. 

Schlayer,  Hedinger,  and  Takayasu,  in  the  Romberg 
Clinic  at  Tubingen,  have  applied  themselves  assiduously 
to  working  out  the  problems  of  pathological  kidney 
function  from  an  experimental  standpoint.  In  this 
country  the  purely  experimental  method  has  yielded 
interesting  results  in  the  hands  of  Rowntree,  Fitz, 
Geraghty,  Christian,  O'Hare,  Folin,  Karsner,  Denis, 
Frothingham,  Austin,  Eisenbrey,  Potter,  Bell,  and 
others.  For  an  interesting  contribution  dealing  with 
the  relation  of  functional  tests  to  pathological  diag- 
nosis, the  reader  is  referred  to  an  article  by  Christian,72 
to  which  an  excellent  bibliography  is  appended.  The 
author  of  this  review  very  justly  concludes  that  tests 
of  renal  function  are  quite  capable  of  demonstrating 
the  bare  fact  (the  important  fact  indeed)  that  the  kid- 
neys are  diseased  but  are  quite  unable  to  disclose  the 
exact  type  of  pathological  lesion  of  the  kidney,  which 
exists  in  any  given  case. 

While  no  functional  test  is  capable  of  disclosing  the 
nature  or  location  of  the  pathological  lesion,  it  may  be 
perfectly  capable  of  disclosing  the  inability  of  the  kid- 
ney to  perform  a  given  function  or  set  of  functions, 
such,  for  example,  as  the  elimination  of  water,  salt, 
urea  or  some  foreign  substance  such  as  lactose  or 
phthalein.  Such  an  inability  on  the  part  of  the  kidney 
will  indicate  a  depreciation  of  its  functional  power  if 

71  Uranium,  ohromates,  mercuric  chloride,  cantharidin,  tartrates, 
etc. 

72  Trans.  Cong.  Amer.  Phys.  and  Surg.,  1913,  IX,  1. 


Tests  of  Kidney  Function  131 

the  test  is  properly  carried  out,  and  this  particular 
information  may  be  important  in  prognosis  and  treat- 
ment although  we  shall  be  unable  with  certainty  to  point 
to  the  seat  of  the  disturbance  in  the  kidney  or  identify 
with  exactitude  the  nature  of  the  underlying  patho- 
logical lesion. 

From  a  medical  standpoint  renal  function  tests  are 
most  important  in  defining  the  state  of  kidney  activity 
in  the  acute  and  chronic  nephritides,  orthostatic  and 
other  albuminurias,  arteriosclerosis,  uremia,  and  myo- 
cardial  insufficiencies. 

In  some  medical  clinics  renal  function  tests  are  ap- 
plied as  a  matter  of  routine  to  all  these  classes  of  cases. 
While  they  do  not  in  themselves  make  the  diagnosis  or 
settle  the  prognosis  it  is  contended,  very  properly  per- 
haps, that  they  will  occasionally  reveal  an  unsuspected 
latent  deterioration  of  kidney  function,  just  as  routine 
blood  examinations  may  reveal  an  unsuspected  leukemia. 

Renal  functional  tests  will  be  of  prognostic  value  be- 
cause they  will  often  serve  to  show  whether  the  disease 
is  stationary,  progressing  or  recovering.  Of  course  it 
hardly  needs  to  be  said  that  renal  function  tests  will 
always  be  carried  out  in  the  medical  clinic  in  conjunc- 
tion with  the  clinical  study  of  the  patient.  A  progres- 
sive lowering  of  the  kidney  function  in  chronic  nephri- 
tis may  indicate  impending  uremia. 

The  question  of  the  prognostic  value  of  renal  func- 
tional tests  has  been  made  the  theme  of  a  very  complete 
and  excellent  article  by  Rowntree.73  According  to  this 
investigator  the  prognostic  value  of  renal  functional 
studies  is  as  great  in  medical  as  it  is  in  surgical  cases. 
In  acute  nephritis,  the  prognosis  depends  upon  the  eti- 
ology more  than  the  result  of  functional  tests.  In  mild 
chronic  nephritis  with  slight  albuminuria  and  cylindru- 
73  Trans.  Cong.  Amer.  Physic,  and  Surg.,  1913,  IX,  23. 


Manual  of  Vital  Function  Testing  Methods 

ria,  slight  hyperpiesis,  moderate  arteriosclerosis  and 
hypertrophy,  the  tests  may  show  how  great  the  func- 
tional deterioration  may  be,  and  the  regular  repetition 
of  the  tests  will  show  whether  the  disease  is  progressing 
or  not.  In  advanced  nephritis  also,  the  proper  func- 
tional tests  will  disclose  the  severity  of  the  disease  and 
the  imminence  of  uremia.  Cases  of  clinically  well- 
marked  nephritis,  even  with  some  uremic  signs  and  a 
less  marked  functional  derangement,  will  be  more  diffi- 
cult to  prognose.  Head  and  brain  complications  cannot 
be  foreseen  by  means  of  renal  functional  tests.  If  the 
renal  function  remains  fair,  say  30%  of  phthalein  out- 
put (Rowntree)  and  the  blood  tests  do  not  show  marked 
cumulative  phenomena  the  prognosis  is  favorable  and 
vice  versa. 

In  cardiorenal  cases  it  is  always  difficult  to  deter- 
mine clinically  just  how  much  the  heart  and  kidney  are 
separately  responsible  for  the  conditions.  Renal  func- 
tional tests  are  of  considerable  service  in  showing  just 
how  far  the  kidney  is  affected.  A  low  phthalein  output 
with  cumulative  signs  in  the  blood  indicate  a  severe 
degree  of  renal  involvement.  In  mere  passive  conges- 
tion these  signs  are  not  apt  to  be  found. 

Moderately  advanced  nephritis  with  slight  heart  fail- 
ure may  show  a  fairly  good  renal  function,  and,  if  so, 
the  prognosis  depends  more  upon  the  response  of  the 
heart  to  treatment  than  on  the  kidney.  If  the  phthalein 
output  increases  in  such  cases  it  is  a  favorable  sign, 
and  if  the  phthalein  output  is  fairly  good  in  an  appar- 
ently severe  cardiorenal  case,  the  heart  may  be  judged 
the  principal  offender  in  the  symptom  complex.  On 
the  contrary,  if  the  phthalein  output  is  very  low  and 
there  are  signs  of  cumulation  in  the  blood  tests  (-{-urea, 
-{-rest  nitrogen,  low  8*)  both  kidneys  and  heart  may  be 
*  5,  symbol  for  freezing  point  of  the  blood. 


Tests  of  Kidney  Function  133 

regarded  as  failing  and  the  prognosis  is  grave. 

As  a  rule  in  cases  of  pure  myocardial  insufficiency 
the  renal  function  tests  give  surprisingly  good  results. 
When  the  kidney  is  passively  congested  for  long  periods, 
however,  as  a  result  of  heart  failure,  the  functional 
tests  give  low  results  just  as  they  do  in  severe  types 
of  nephritis.  The  prognosis  becomes  proportionately 
lugubrious. 

2.  Surgical  Application. — The  surgeon  is  extremely 
interested  in  the  problems  of  renal  function.  With  him 
the  question  often  becomes  a  very  vital  one  in  connec- 
tion with  important  and  serious  operations  upon  the 
genitourinary  tract.  The  proper  selection  of  tests  is  a 
matter  of  great  importance  to  the  surgeon.  Geraghty 
rightly  insists  that  it  is  only  through  familiarity  with 
the  reliability,  limitations,  and  significance  of  findings 
of  individual  tests  of  renal  function,  in  their  relation  to 
various  types  of  disease  and  various  kinds  of  problems 
to  be  solved,  that  a  proper  selection  can  be  made. 

Certain  of  the  tests  or  combinations  of  tests  are  more 
suitable  to  surgical  investigations,  while  other  tests  or 
combinations  of  tests  may  be  of  greater  value  to  the 
internist. 

In  discussing  the  utility  of  renal  function  tests  to  the 
surgeon,  we  shall  draw  freely  upon  Geraghty,  since  he 
more  than  any  other  investigator  has  identified  himself 
in  his  researches  with  the  question  of  their  value  and 
limitations  in  surgical  practice.  Some  of  the  tests  of 
renal  function  are  adapted  to  estimating  the  total  func- 
tional capacity  of  the  kidneys  at  any  given  time.  Other 
tests  are  not  of  great  use  in  this  respect  but  are  of 
considerable  importance  in  determining  the  relative 
functional  capacity  of  the  organs  when  applied  to  the 
excretion  obtained  by  ureteral  catheterization.  Finally 
there  are  a  few  tests  which  are  apparently  useful  in 


134      Manual  of  Vital  Function  Testing  Methods 

both  cases.  As  an  illustration,  it  is  known  that  the 
estimation  of  urea  output  in  a  24-hour  specimen  is 
of  no  great  value  by  itself  in  judging  the  total  func- 
tional capacity  of  the  kidneys,  while  comparisons  of 
urea  elimination  in  catheterized  specimens  from  both 
sides  may  give  very  important  information. 

From  a  purely  practical  standpoint,  as  was  men- 
tioned under  preliminary  considerations,  all  tests  for 
kidney  function  come  under  two  general  heads:  1. 
Tests  to  determine  how  much  of  a  given  substance  is 
excreted  by  the  kidney  or  kidneys,  comparing  the 
amount  with  what  is  known  to  be  normal.  The  sub- 
stance excreted  may  be  one  which  is  normally  found 
in  the  urine  or  it  may  be  a  substance  artificially  intro- 
duced into  the  circulation  to  determine  the  capacity  of 
the  kidneys  to  eliminate  it.  2.  The  blood  may  be  exam- 
ined for  substances  which  are  normally  passed  through 
the  kidneys,  with  a  view  of  detecting  an  accumulation 
of  such  substances  in  the  body,  such  accumulation  being 
regarded  as  an  evidence  of  defective  kidney  function. 

Renal  functional  tests  arc  especially  valuable  to  the 
genitourinary  surgeon  in  two  types  of  cases  :  1st,  Sur- 
gical diseases  of  the  kidney  secondary  to  obstructions 
in  the  lower  urinary  tract.  2nd,  Unilateral  and  bilateral 
surgical  diseases  of  the  kidney  not  associated  with  ob- 
struction. 

Rowntrce  and  Geraghty,  in  many  of  their  publica- 
tions concerning  the  phenolsulphonephthalein  test,  have 
called  attention  to  the  fact  that  inasmuch  as  many  cases 
with  obstruction  in  the  lower  tract  also  have  hydroneph- 
rosis,  pyoncphrosis,  pyelonephritis,  or  pressure  at- 
rophy, an  examination  of  the  total  function  by  means  of 
the  phthalein  test  will  often  show  diminished  functional 
activity.  In  these  cases  the  urinalysis  may  be  mislead- 
ing, for  urea  output  and  total  solids  secretion  may  be 


Tests  of  Kidney  Function  135 

normal,  and  yet  the  kidney  function  may  be  so  unstable 
that  the  shock  of  a  surgical  operation,  such,  for  exam- 
ple, as  prostatectomy,  may  be  sufficient  to  inhibit  func- 
tion altogether,  and  death  will  result.  In  just  such  cir- 
cumstances they  believe  a  total  examination  by  phtha- 
lein  will  serve  to  differentiate  these  cases  with  severe 
from  those  with  slight  renal  involvement. 

Experience  has  shown  that  cases  of  obstruction  in 
which  the  phthalein  output  is  deficient  may  be  so  greatly 
improved  by  preliminary  treatment  with  proper  drain- 
age that  the  subsequent  radical  operation  may  be  per- 
formed with  greatly  diminished  risk. 

According  to  Geraghty  the  phthalein  test  affords  the 
truest  index  of  functional  capacity  of  the  kidney  for 
surgical  work.  The  diastase  test  and  urea  estimation 
are,  he  thinks,  of  equal  value,  but  are  unreliable  indices 
of  functional  capacity ;  but  when  persistently  low 
values  are  given  by  them  they  may  be  important  from  a 
prognostic  point  of  view.  Estimations  of  blood  urea 
and  incoagulable  blood  nitrogen  are  extremely  impor- 
tant when  they  are  associated  with  the  phthalein  test. 
When  all  three  are  positive  they  are  extremely  sig- 
nificant. 

The  functional  tests,  one  and  all,  can  never  be  said 
to  arbitrarily  answer  the  important  question,  when  to 
operate  and  when  not  to  operate,  because  there  are 
other  factors  to  consider  in  a  surgical  case  besides  renal 
function.  If  the  phthalein  test  is  very  low  operation 
should  be  postponed  until  efforts  are  made  by  improved 
drainage  (either  by  suprapubic  cystotomy  or  by  cathe- 
ter) to  bring  about  improvement  in  the  functional 
capacity  of  the  kidneys. 

In  the  second  group  of  surgical  cases  above  men- 
tioned, namely,  unilateral  surgical  kidney  diseases,  the 
relative  functional  power  of  the  kidneys  is  a  question 


136      Manual  of  Vital  Function  Testing  Methods 

of  vital  importance.  It  is  here  that  ureteral  catheter- 
ization  is  of  supreme  importance,  for  by  this  means  the 
excretion  from  each  kidney  can  be  separately  obtained. 

Many  functional  tests,  such  as  urea  estimations,  cer- 
tain chromoscopic  tests,  as  indigo  carmin  and  methylene 
blue,  cryoscopy,  diastase  estimation,  phloridzin  reac- 
tion, and  experimental  polyuria,  give  information  only 
with  respect  to  the  relative  functional  value  of  the  two 
kidneys.  This  is  insufficient,  since  one  kidney  may  be 
doing  a  great  deal  more  work  than  the  other,  and  yet  be 
incapable  of  doing  the  work  of  both,  and  this  is  the 
question  of  vital  importance  to  the  surgeon,  requiring 
a  definite  answer  in  each  individual  case.  The  phenol- 
sulphonephthalein  test  has  proven  of  special  value  here 
because  by  it  not  only  is  an  idea  of  the  total  functional 
capacity,  but  also  a  quantitative  estimate  of  the  work 
done  by  each  kidney  obtained. 

There  are  two  difficulties,  however,  which  belong  to 
all  tests  of  renal  function  when  carried  out  with  ureteral 
catheterization ;  one  is  inhibition  of  function  produced 
by  the  presence  of  the  catheter  in  the  ureter ;  the  other 
is  leakage  around  the  catheter.  Special  catheters  are 
now  used  to  prevent  the  latter  difficulty.  As  to  the  first, 
the  best  method  of  procedure  is  to  test  the  total  func- 
tional capacity  with  phthalein  before  ureteral  catheter- 
ization is  performed.  If  the  total  phthalein  output  is 
nearly  normal  one  kidney  at  least  is  satisfactorily  nor- 
mal. If,  after  ureteral  catheterization,  one  kidney  is 
found  with  an  exceedingly  low  output,  which,  together 
with  the  clinical  findings,  indicates  that  this  is  the  dis- 
eased organ,  it  may  be  safely  removed  even  if  the  output 
in  the  sound  side  is  low,  for  here  the  natural  inference 
is  that  inhibition  has  produced  the  deficiency.  Inas- 
much, however,  as  inhibition  is  not  necessarily  equal  on 
the  two  sides  it  will  always  be  necessary  to  combine  the 


Tests  of  Kidney  Function  137 

phthalein  test  with  comparison  of  diastase  and  particu- 
larly urea  percentages,  on  the  two  sides.  The  actual 
procedure  recommended  by  Geraghty  is,  first,  the  esti- 
mation of  total  output  by  phthalein  and  the  estimation 
of  relative  function  by  ureteral  catheterization  com- 
bined with  pigment,  diastase  and  urea  estimation  on  the 
two  sides.  If  the  phthalein  output  is  low,  cryoscopy  of 
the  blood  serum  and  estimation  of  blood  urea  may 
profitably  be  done. 

Geraghty  says :  "Most  of  the  criticism  of  functional 
tests  has  come  from  those  who  have  not  used  them,  and 
are  unfamiliar  with  the  nature  of  the  information  sup- 
plied. It  is  true  that  in  the  vast  majority  of  cases  a 
successful  nephrectomy  on  the  diseased  side  from  the 
standpoint  of  renal  function,  can  be  performed  when 
the  urine  from  the  opposite  kidney  is  found  apparently 
normal  on  analysis.  Unfortunately,  however,  the  prob- 
lems are  not  always  so  simple.  Cases  of  bilateral  dis- 
ease are  encountered  in  which  a  knowledge  of  the  renal 
function  becomes  of  absolutely  vital  importance,  and  in 
which  every  source  of  information  must  be  called  upon 
before  the  proper  line  of  procedure  can  be  employed. 
Again,  in  certain  cases,  particularly  those  of  tubercu- 
losis, it  may  be  possible  to  introduce  a  catheter  only  on 
one  side.  In  such  cases  one  must  depend  to  a  great 
extent  upon  the  information  derived  from  function  tests 
as  to  the  condition  of  the  opposite  kidney  since  the  cys- 
toscopic  appearance  of  the  ureteral  orifice  is  frequently 
deceptive.  The  recognition  of  hypoplastic  and  infantile 
kidney  is  practically  impossible  without  functional  esti- 
mation. The  infantile  kidney  is  a  particularly  danger- 
ous type  because  the  urine  which  is  secreted  by  the  kid- 
ney is  apparently  normal  in  every  respect  except  that 
of  quantity.  Functional  estimation  has  proved  also  of 
great  value  in  the  differentiation  between  pyelitis  and 


138      Manual  of  Vital  Function  Testing  Methods 

pyelonephritis.  In  pyelitis  the  renal  function  is  prac- 
tically normal,  while  in  pyelonephritis  there  is  dimin- 
ished function." 

Selection  and  Practicability  of  Renal  Function  Tests 

In  this  regard  we  can  do  no  better  than  quote  the 
words  of  Geraghty,  spoken  at  the  conference  on  Renal 
Function  Tests  at  the  ninth  triennial  meeting  of  the 
Congress  of  American  Physicians  and  Surgeons, 
1913  74: 

"The  number  of  functional  tests  has  become  so 
great  that  it  is  impracticable  to  employ  all  of  them  in 
any  individual  case ;  and,  even  if  not  impracticable, 
nothing  would  be  gained  by  employing  all  of  these  tests. 
The  information  furnished  by  many  is  of  the  same  char- 
acter, but  more  accurately  furnished  by  one  test  than 
by  others.  For  example,  there  is  a  parallelism  between 
the  excretion  of  the  different  dye  substances;  but  as 
phthalein  furnishes  more  accurately  all  the  information 
obtainable  from  this  group  of  substances,  no  advantage 
attaches  to  the  employment  of  all. 

"For  chromocystoscopy  alone  indigo  carmin  is  un- 
questionably the  test  of  choice.  The  estimation  of  rest 
nitrogen  and  blood  urea  bear  about  the  same  signifi- 
cance. Lately  we  have  discarded  estimations  of  resid- 
ual nitrogen  in  the  blood  and  are  depending  entirely 
upon  the  blood  urea  determined  by  Marshall's  method 
or  upon  cryoscopy  for  evidence  of  cumulative  phe- 
nomena. 

"From  a  practical  standpoint  certain  tests  can  be 

entirely  discarded  without  loss,  such  as  cryoscopy  of 

the  urine  and  electrical  conductivity  of  the  urine.    Total 

urea  estimations  in  urine  are  of  doubtful  value  and  dias- 

74  See  Trans.  Cong.  Amer.  Phys.  and  Surg.,  1913,  IX,  45. 


Tests  of  Kidney  Function  139 

tase  determination  furnishes  only  information  that  is 
obtainable  more  accurately  and  quickly  by  other  means. 
Certain  other  tests,  such  as  potassium  iodide  elimina- 
tion, can  be  discarded  as  furnishing  at  times  unreliable 
information.  We  have  seen  potassium  iodide  excretion 
delayed  in  cases  with  normal  function  (proven  by  sub- 
sequent history)  and  excreted  within  normal  limits  in 
cases  of  the  most  severe  nephritis.  The  tests  which 
we  consider  of  the  greatest  value  in  the  excretory  group, 
based  upon  actual  experience,  are:  Phthalein,  lactose, 
and  chlorides ;  and  of  the  tests  of  retention,  blood  urea, 
rest  nitrogen  and  cryoscopy.  The  indications  for  the 
specific  employments  of  the  individual  tests  are  as  fol- 
lows: 

"Chloride  estimation  in  the  urine  is  useful  in  all 
forms  of  nephritis  and  cardiorenal  disease,  especially 
if  oedema  is  present. 

"Lactose  is  indicated  for  the  detection  of  slight  in- 
jury to  the  kidneys  and  also  in  severe  nephritis,  since 
its  suppression  indicates  a  bad  prognosis.  It  is  not  par- 
ticularly helpful  in  surgical  diseases. 

"Of  the  retention  tests  either  blood  urea,  rest  nitro- 
gen or  cryoscopy  is  indicated  wherever  there  is  a  severe 
lesion  of  the  kidneys. 

"We  consider  that  one  of  these  tests  should  be  used 
as  a  routine  in  conjunction  with  phthalein  wherever 
functional  tests  are  desirable,  particularly  if  the  phtha- 
lein function  is  low. 

"Tests  in  conjunction  with  ureteral  catheterization : 
in  this  connection,  phthalein,  urea  in  urine,  and  urinary 
diastase  are  most  serviceable.  The  diastase  and  urea 
give  practically  the  same  information,  but  only  give 
relative  functional  values,  while  phenolsulphonphthalein 
p-ives  relative  and  absolute  values.  The  total  function 

O 

should  always  be  estimated  by  means  of  phthalein  with- 


14»0      Manual  of  Vital  Function  Testing  Methods 

out  ureteral  catheterization,  in  order  to  detect  the 
amount  of  catheter  inhibition,  should  this  exist.  Where 
severe  bilateral  lesions  exist,  one  of  the  retention  tests 
should  be  used. 

"As  to  practicability,  the  simplest  and  easiest  test  is 
undoubtedly  the  phthalein  test,  as  it  requires  the  least 
amount  of  time  and  apparatus. 

"The  lactose  test,  if  quantitative  determination  is  re- 
quired, necessitates  the  employment  of  an  expensive  po- 
lariscope.  Furthermore  the  preparation  of  the  lactose 
for  injection  requires  attention  and  consumes  time.  Its 
use  also  requires  familiarity  with  the  technic  of  in- 
travenous injection. 

"Diastase  requires  the  daily  quantitative  preparation 
of  soluble  starch,  accurately  graduated  pipettes,  a  large 
series  of  test  tubes,  a  water  bath,  and  one-fiftieth  nor- 
mal iodine  solution.  For  total  estimation  it  requires 
24-hour  specimens  of  urine  with  preservatives.  The 
time  necessary  for  a  simple  determination  is  scarcely 
warranted  by  the  information  obtained.  Urea  estima- 
tions of  the  urine  can  be  accurately  and  rapidly  done 
by  the  Marshall  method ;  and  from  the  standpoint  of 
practicability  it  leaves  little  to  be  desired.  It  is  useful 
only  in  conjunction  with  ureteral  catheterization. 

"Chloride  estimation  requires  standardized  solutions 
and  carefully  graduated  apparatus  when  accurately 
done.  It  consumes  considerable  time,  and,  besides,  re- 
quires daily  collections  of  the  urine  with  the  knowledge 
of  the  daily  chloride  intake. 

"All  retention  tests  require,  of  course,  the  withdrawal 
of  blood ;  and  cryoscopy  of  the  blood  is  undoubtedly  the 
simplest,  provided  that  proper  apparatus  is  at  hand. 
It  requires  careful  attention  to  the  details  and  con- 
sumes considerable  time. 

"Blood  urea  can  be  done  by  either  the  Folin  or  the 


Tests  of  Kidney  Function  141 

Marshall  method,  and  the  total  rest  nitrogen,  preferably 
by  Folin's  method ;  but  any  of  these  methods  is  imprac- 
ticable for  the  general  practitioner. 

"Where  only  one  test  can  be  employed  the  most  value 
is  unquestionably  to  be  obtained  from  the  use  of  phtha- 
lein ;  and  this  is  particularly  so  from  the  standpoint  of 
the  surgeon." 


CHAPTER  III 
TESTS  OF  PANCREATIC  FUNCTION 

GENERAL   CONSIDERATIONS 

As  Stadmiillcr  1  rightly  says,  "The  recognition  in  the 
living  subject  of  pathological  conditions  of  the  pan- 
creas belongs,  without  doubt,  to  the  more  difficult  prob- 
lems of  the  diagnostic  technic  of  the  present  day." 

Aser  2  also  said  years  ago  that  there  is  no  organ  in 
the  body  in  which  such  a  disparity  exists  between  its 
known  physiological  importance  and  our  capacity  to 
clinically  estimate  its  functioning  power. 

In  other  words,  the  enormous  importance  of  the  pan- 
creas as  a  digestive  organ  and  as  a  gland  of  internal 
secretion  is  granted,  thanks  to  the  work  of  Von  Mering, 
Minkowski,  Pawlow,  Boldyreff,  and  many  others.  Our 
ability  to  estimate  the  functioning  power,  the  physio- 
logical capacity,  the  anatomical  condition  of  the  organ 
in  a  given  case  is  limited. 

The  importance  of  the  pancreas  as  a  digestive  gland 
is  very  great.  It  is  the  only  gland  which  furnishes  an 
enzyme  for  each  class  of  foodstuffs. 

The  activated  proteolytic  ferment  trypsin  breaks  up 
protein  into  simpler  structures  (amino  acids)  than  the 
gastric  juice.  Amylopsin  or  pancreatic  diastase  con- 
verts starch  into  sugar.  Steapsin  or  pancreatic  lipasc 

'Archiv.  of  Diag.,  1911,  IV,  20. 

"Nothnagel's  Spec.  Path,  und  Therap.,  Wien,  1898,  I. 

142 


Tests  of  Pancreatic  Function  143 

splits  neutral  fats  into  fatty  acids  and  glycerine. 
Glaessner  has  estimated  that  the  pancreas  pours  into 
the  duodenum  through  the  ampoule  of  Vater  perhaps  a 
pint  or  more  of  its  mixed  secretion  per  day. 

But  beyond  this  great  act,  which  a  priori  would  ap- 
pear to  be  more  than  sufficient  for  a  single  organ,  the 
pancreas  elaborates  a  mysterious  secretion  which  pre- 
sides in  an  equally  mysterious  way  over  the  sugar 
metabolism  of  the  body. 

Von  Mering  and  Minkowski  in  1889  discovered  that 
typical  diabetes  follows  total  extirpation  of  the  pan- 
creas in  dogs.  This  fact,  which  has  received  an  immense 
amount  of  experimental  corroboration,  still  stands  out 
as  an  epoch-making  discovery  in  the  history  of  pan- 
creatic physiology  amidst  much  that  is  obscure  and  un- 
certain. 

It  is  pretty  generally  agreed  that  the  internal  secre- 
tion of  the  pancreas  is  elaborated  in  the  islands  of 
Langerhans,  closely  crowded  groups  of  polygonal  cells 
without  excretory  duct  of  any  kind  scattered  in  the 
stroma  of  the  gland  between  the  external  secreting 
acini  and  surrounded  by  a  profusely  developed  net  of 
blood  vessels. 

Besides  controlling  the  carbohydrate  intermediate 
metabolism  of  the  body  the  internal  secretion  of  the  pan- 
creas is  claimed  by  Loewi  and  some  others  to  exert  an 
inhibitory  effect  upon  the  sympathetic. 

From  the  standpoint  of  the  clinician  it  is  an  exceed- 
ingly difficult  matter  to  determine  the  existence  of 
pancreatic  disease,  and  to  ascertain  its  nature.  All 
the  customary  methods  of  examination  are,  of  course, 
employed  in  such  a  search.  Inspection,  palpation, 
blood  examination,  and  a  careful  study  of  the  semiology 
are  made  use  of.  The  subjects  of  pancreatic  semiology, 
pain,  tenderness,  tumor,  pressure,  etc.,  and  pancre- 


144      Manual  of  Vital  Function  Testing  Methods 

atic  exploration  arc  extremely  important  aids  and  in- 
dispensable adjuncts  in  pancreatic  diagnosis.  They 
do  not  come,  however,  under  the  functional  investiga- 
tion of  pancreatic  activity,  and  will,  therefore,  be 
necessarily  left  undiscussed  in  this  place.3 

In  considering  the  question  of  studying  the  functional 
capacity  of  the  pancreas,  two  possibilities  become  im- 
mediately apparent.  (A)  Functional  investigation 
may  be  made  of  the  pancreas  regarded  as  an  organ 
of  external  or  digestive  secretion,  and  (B)  the  func- 
tional examination  may  relate  to  an  inquiry  concerning 
the  internal  secretory  activity  of  the  organ,  its  power, 
in  other  words,  of  adequately  performing  its  endocrin- 
ous  or  metabolic  function. 

A.    TESTS    FOR    PANCREATIC    FUNCTION,    WHICH    CONCERN 
THE  EXTERNAL  OR  DIGESTIVE  ACTIVITY  OF  THE  ORGAN 

These  may  be  divided  into  four  subdivisions,  as  fol- 
lows: 

1.  Proteid  digestion  tests. 

2.  Fat  digestion  tests. 

3.  Starch  digestion  tests. 

4.  Demonstration   of  pancreatic   ferments  in   secre- 

tions and  excretions. 

The  protcid  digestion  tests  are:  Demonstration  of 
waste  muscle  fibre  in  the  stools,  the  so-called  azotor- 
rhoea  or  creatorrhoea.  Schmidt's  test  for  digestion  of 
nuclei.  Sahli's  glutoid  capsule  test. 

The  fat  digestion  tests  are:  Demonstration  of  ex- 
cess fat  in  the  stools,  so-called  steatorrhoea.  Identifica- 
tion of  split  fat  in  the  stools.  Winternitz  Diagnosti- 
cum. 

8  Consult  Opie's  Text  Book,  Diseases  of  the  Pancreas. 


Tests  of  Pancreatic  Function  145 

The  starch  digestion  test  consists  of  identification  of 
undigested  starch  in  the  stools. 

Besides  the  above  tests  there  have  been  devised  special 
qualitative  and  quantitative  methods  of  identifying  the 
various  pancreatic  ferments  themselves  (trypsin,  amyl- 
ase  and  lipase)  in  the  stools,  urine  and  gastric  contents. 

It  is  somewhat  difficult,  therefore,  to  separate  the 
operations  of  routine  urinalysis  and  coproanalysis  in- 
tended to  show  the  presence  or  absence  of  pancreatic 
enzymes,  from  certain  special  tests  which  have  been  de- 
vised with  the  express  purpose  of  testing  pancreatic 
function.  For  example,  Schmidt's  test  for  nuclear  di- 
gestion, and  Sahli's  glutoid  capsule  test  might,  upon 
superficial  consideration,  be  considered  as  special  tests 
for  pancreatic  function,  but  in  reality  they  are  both 
merely  special  methods  of  demonstrating  the  presence 
or  absence  in  the  intestine  of  pancreatic  enzymes. 

However,  the  fact  that  in  the  performance  of  these 
tests  something  particular  is  done  in  the  way  of  special 
preparation  with  a  certain  definite  end  in  view,  would, 
in  all  likelihood,  insure  their  inclusion  in  any  scheme  or 
list  of  functional  pancreatic  tests. 

All  the  other  tests  mentioned  in  the  above  synopsis 
are,  in  reality,  only  special  methods  of  urinalysis  or 
fecal  examination. 

The  same  difficulty  of  classification  becomes  apparent 
when  we  come  to  consider  the  tests  of  internal  secre- 
tion. The  Cammidge  test,  as  it  is  called,  is  but  a 
specially  technical  urinalysis. 

The  Loewi  test  for  pupillary  reaction  to  adrenalin 
and  the  test  for  alimentary  glycosuria  might  be  said  to 
answer  all  the  requirements  of  special  functional  tests, 
but  if  our  knowledge  of  pancreatic  function  were  lim- 
ited to  these  experimental  inquiries  alone,  it  would  be 


146      Manual  of  Vital  Function  Testmg  Methods 

meagre  indeed. 

From  all  these  considerations  it  will  be  apparent  that 
any  attempt  to  give  a  description  of  methods  of  study- 
ing pancreatic  function  must  include  all  of  the  above- 
mentioned  methods,  although  a  very  strict  interpreta- 
tion might  relegate  some  or  many  of  them  to  the  domain 
which  is  usually  covered  by  books  dealing  with  chemical 
or  microscopical  laboratory  methods. 

B.    TESTS    FOR    PANCREATIC    FUNCTION    WHICH    CONCERN 

THE  INTERNAL  OR  METABOLIC  FUNCTION  OF 

THE    ORGAN 

There  are  three  tests  which  belong  to  this  class. 

1.  The  Cammidge  reaction. 

2.  Loewi's  pupillary  reaction. 

3.  Provocative  alimentary  glycosuria. 

1.  Proteid  Digestion  Tests.  Estimation  of  Undigested 
Protein  in  the  Stools  as  a  Means  of  Determin- 
ing Pancreatic  Hypofunction 

The  patient  is  placed  for  three  days  on  Schmidt's 
test  diet.  This  diet  is  as  follows:  1.5  liters  of  milk, 
100  gins,  of  zwieback,  2  eggs,  50  gms.  of  butter,  125 
gms.  of  beef,  190  gms.  of  potatoes,  and  gruel  made  from 
80  gms.  of  oatmeal.  In  this  diet  are  contained  102  gms. 
of  albumen,  111  gms.  of  fat,  191  gms.  of  carbohydrates; 
making  a  total  of  2234  calories  of  energy. 

According  to  Schmidt  the  diet  is  distributed  thro 
the  day  as  follows:  Morning,  .5  liter  of  milk  (if  milk 
does  not  agree  .5  liter  of  cocoa  made  from  20  gms.  of 
cocoa  powder,  10  gms.  sugar,  400  gms.  water  and  100 
gms.  milk  are  substituted),  50  gms.  zwieback;  noon,  125 


Tests  of  Pancreatic  Function  147 

gms.  chopped  beef  (raw  weight)  broiled  rare,  with  20 
gms.  of  butter  (the  interior  of  the  meat  must  be  raw), 
250  gms.  of  potato  broth  made  of  190  gms.  of  mashed 
potatoes  mixed  with  100  c.c.  of  milk  and  10  gms.  of  but- 
ter ;  afternoon,  same  as  morning ;  evening,  same  as  fore- 
noon. 

It  would  be  well  if  investigators  should  agree  to  use 
this  well-known  standard  diet  so  that  comparisons  of 
results  could  be  made. 

Pratt,4  while  using  the  diet,  recommends  that  the 
whole  quantity  be  given  in  three  meals  instead  of  five, 
conforming  thus  to  American  custom. 

The  Schmidt  diet,  containing  as  it  does  a  good 
amount  of  all  three  varieties  of  foodstuffs,  is  adapted  to 
all  tests  which  involve  an  examination  of  the  feces. 

The  presence  of  azotorrhoea  or  defective  proteid 
digestion  due  to  deficiency  of  trypsin  zymase,  is  deter- 
mined by  examining  the  feces  microscopically  after  the 
test  diet. 

Meat  consists  of  connective  tissue  and  muscle  fiber. 
Connective  tissue  is  digested  promptly  by  the  gastric 
juice,  the  muscle  fiber  by  trypsin.  Large  quantities  of 
striated  muscle  fiber  in  the  feces  may  indicate  defective 
pancreatic  activity. 

The  bulkiness  of  the  stools  should  also  be  noted. 
Oser,  Musser  and  others  have  claimed  that  there  is 
no  single  symptom  of  pancreatic  disease  of  greater 
significance  than  bulkiness  of  the  stools.  The  dried 
weight  of  the  stools  may  be  rather  readily  ascertained. 
A  ventilating  hood  and  scales  are  all  that  are  necessary. 
If  the  pancreatic  juice  is  not  appearing  in  the  bowel  the 
dried  stools  will  weigh  more  and  the  stools  themselves 
will  be  more  than  ordinarily  voluminous. 

In  six  healthy  individuals   on  Schmidt's  diet  Pratt 

4  Amer.  Jour.  Med.  Sc.,  1913,  CXLIII,  313. 


148      Manual  of  Vital  Function  Testing  Methods 

found  the  average  weight  of  the  dried  feces  to  be  54.3 
gins.  The  maximum  was  62  and  the  minimum  45  gms. 

Schmidt's  Cell  Nuclei  Test  for  Pancreatic  Suf- 
ficiency.5— According  to  Schmidt,  the  nuclei  of  animal 
cells  is  digested  only  by  the  pancreatic  enzymes.  Con- 
siderable has  been  written  pro  and  con  concerning  this 
test  and,  although  it  does  not  appear  to  be  extensively 
used,  there  is  no  doubt  that  it  is  not  devoid  of  a  certain 
value. 

Technic. — Raw  beef  somewhat  fibrous  is  cut  into 
cubes  of  .5  c.cm.  These  are  hardened  in  alcohol  and 
placed  in  small  bags  of  coarse  silk  gauze.  Before  using 
they  must  be  soaked  several  hours  in  water.  The  bags 
are  recovered  in  the  stools,  hardened,  paraffined,  cut  and 
stained,  and  the  sections  mounted  and  examined  micro- 
scopically for  nuclei.  If  the  nuclei  are  not  digested, 
they  will  take  the  stain  and  become  visible.  Thymus 
gland  has  been  substituted  for  the  meat  by  Einhorn. 

Kashiwado,  one  of  Schmidt's  pupils,  has  altered  the 
original  test  by  giving  a  powder  consisting  of  equal 
parts  of  stained  thymus  nuclei  and  lycopodium.  The 
mixture  is  given  in  two  capsules,  each  containing  .25 
gms,  at  the  evening  meal.  The  stool  is  examined  for 
stained  nuclei. 

In  performing  the  Schmidt  test  the  sac  must  be 
recovered  in  the  feces  before  the  expiration  of  30  hours 
at  the  latest,  otherwise  a  longer  sojourn  in  the  bowel 
will  enable  the  bacterial  enzymes  to  dissolve  the  nuclei. 

Sahli's  G  Glutoid  Capsule  Test  of  Pancreatic  Func- 
tion.— The  glutoid  capsules  used  in  this  test  are  made 
of  gelatin  and  hardened  in  formalin.  This  is  intended 

•  Verhandl.  d.  Kong.  f.  inn.  Med.,  1904,  XXI,  335. 
6  Deutsch.  med.  Wchnschr.,   1897,  XXIII,  6;  also  Deutsch.   Ar- 
chiv  f.  klin.  Med.,  1898,  LXI,  475. 


Tests  of  Pancreatic  Function  149 

to  make  them  resist  digestion  by  the  gastric  juice,  to 
permit  of  their  entering  the  bowel,  there  to  be  softened 
and  disintegrated  by  the  pancreatic  juice  if  it  be  pres- 
ent in  sufficient  amount.  It  is  the  trypsin  zymase  which 
affects  this  solution. 

The  capsules  may  be  filled  with  sodium  iodide,  iodo- 
form  or  salol.  The  last  is  usually  employed.  Salol  is 
split  up  by  the  pancreatic  juice  into  salicylic  acid  and 
phenol.  The  former  is  eliminated  by  the  kidney  and 
escapes  in  the  urine  as  salicyluric  acid,  which  is  easily 
recognized  in  the  excretion  by  the  violet  color  produced 
by  adding  to  the  urine  a  few  drops  of  a  solution  of 
ferric  chloride. 

Normally  the  reaction  is  obtained  in  five  hours. 
Sahli  did  not  disclose  the  precise  manner  of  preparing 
the  capsules  and  this,  according  to  Pratt,  has  hindered 
the  generalization  of  the  test  which  is  so  extremely 
simple. 

The  capsules  are  made  and  sold  by  Hansmann  of  St. 
Gallen,  Switzerland. 

Sailer 7  says  that  a  satisfactory  capsule  may  be 
prepared  by  placing  ordinary  gelatin  capsules  in  pure 
formalin  for  three  minutes. 

This  test  is  practically  the  same  as  that  introduced 
by  Sahli  for  estimating  gastric  motility.  Its  extreme 
facility  of  execution  would  make  it  an  excellent  test  if 
there  were  unanimity  in  the  findings.  Unfortunately 
this  is  not  the  case  and  at  the  present  time  no  one  would 
pretend  to  depend  upon  its  results  alone,  though  it 
seems  undoubtedly  true  that  in  the  absence  of  pyloric 
spasm  or  stenosis,  the  capsule  test  of  Sahli  is  worth 
considering  from  a  corroborative  point  of  view. 

7  Amer.  Jour.  Med.  Sc.,  1910,  CXL,  330. 


150      Manual  of  Vital  Function  Testing  Methods 

2.  Fat  Digestion  Tests.  Demonstration  of  Excess  of 
Fat  in  the  Stools  (Steatorrhaea)  and  Diminu- 
tion of  Split  Fats  in  the  Stools  as  a  Means  of 
Estimating  Pancreatic  Insufficiency 

Here  the  insufficiency  of  pancreatic  function,  if  it 
exists,  is  reflected  upon  the  fat-splitting  activity  of  the 
external  secretion  and  shows  itself  by  phenomena  which 
are  due  to  diminution  or  absence  of  the  lipasic  enzyme 
of  the  juice. 

Steatorrhoea,  or  increased  fat  in  the  stools,  is  known 
to  be  common  in  pancreatic  disease.  The  light  color 
of  the  stools  is  an  important  macroscopic  feature.  They 
may  be  almost  white.  The  stools  are  often  rancid  in 
smell  and  bulky.  Since  the  stools  in  icterus  may  also 
be  fatty  it  may  be  necessary  to  test  for  bile  in  order  to 
make  sure  that  the  pale  color  is  not  due  to  hydrobiliru- 
bin.  When  fat  crystals  are  present  in  excess,  the  stools 
have  a  metallic  lustre  like  aluminum.  A  white  stool, 
fluid  when  passed  and  becoming  solid  on  cooling,  is  fatty 
and  is  said  to  be  quite  characteristic  of  defective  pan- 
creatic secretion.  The  most  important  function  of  pan- 
creatic lipase  is  to  split  up  the  neutral  fats  into  fatty 
acids  and  glycerine.  The  free  fatty  acids  combine  with 
the  alkalies  of  the  pancreatic  juice  to  form  readily 
assimilable  soaps. 

If  the  functional  activity  of  the  pancreas  is  deficient, 
one  important  consequence  will  be  a  considerable  dim- 
inution in  the  amount  of  split  fats,  and  hence  of 
soaps.  The  fat  will  remain  unsplit,  therefore  unassirnil- 
able  and  consequently  unabsorbed. 

Normally  from  7  to  11  %  of  the  fat  ingested  in  the 
food  escapes  action  by  the  pancreatic  juice  and  is 
passed  in  the  stools.  If  bile  is  absent  from  the  intestine 
because  of  occlusion  of  the  duct,  there  will  be  incomplete 


Tests  of  Pancreatic  Function  151 

emulsification  of  the  fats  and  consequent  reduction  of 
pancreatic  effects.  Under  such  circumstances  as  much 
as  45%  of  the  fats  ingested  may  escape  in  the  stools. 
If,  in  a  case  of  icterus,  the  loss  of  fat  in  the  stools  is  less 
than  60%  the  pancreas  is  probably  not  implicated.  If 
the  fat  loss  exceeds  60%  it  points  to  pancreatic  disease. 

Under  the  microscope,  fat  appears  in  the  stools  as 
droplets,  needle  crystals,  or  as  structureless  plates  or 
flakes.  Unfortunately  the  quantitative  estimation  of 
fat  in  the  stools  is  not  a  simple  matter.  The  stools  must 
first  be  dried  on  a  water  bath;  the  neutral  fats  and 
fatty  acids  are  extracted  in  a  Soxlet  apparatus  with 
ether,  from  a  known  quantity  of  dried  stool ;  the  residue 
is  treated  with  diluted  HC1  to  convert  soaps  into  fatty 
acids  and  these  are  extracted  in  the  same  manner.  The 
amount  of  free  acid  in  the  first  extract  is  calculated  with 
titration  with  alkali. 

Like  the  Cammidge  reaction  or  test  (v.i.)  the  quanti- 
tative estimation  of  fat  in  the  feces  is  not  to  be  regarded 
as  a  clinical  procedure  likely  to  be  carried  out  by  the 
physician.  The  method  requires  some  apparatus  and 
more  chemical  experience  than  the  clinician  is  likely  to 
possess  and,  besides,  is  time  consuming.  Of  course,  in 
many  hospitals,  the  examination  can  readily  be  made. 
It  is  not  considered  advisable  to  give  the  details  of  the 
method  for  fat  extraction  and  quantitative  estimation, 
the  skeleton  of  which  is  above  outlined,  especially  as 
the  details  may  readily  be  obtained  from  texts  on 
chemical  diagnosis.  For  convenience  two  references 
may  be  given — Sahli  8  and  Wood.9 

Winternitz's  Test  of  Pancreatic  Fat-splitting  Func- 
tion. Winternitz  Diagnostikum.  The  Sajodin  Test. — 
This  test  is  founded  upon  the  fat-splitting  power  of 

8  Diagnostic  Methods,   190,5,  p.  446. 

9  Chemical  and  Microscopical  Diagnosis,  1909,  p.  334. 


152      Manual  of  Vital  Function  Testmg  Methods 

steapsin  to  set  free  iodine  from  iodine-containing  fats. 
Winternitz  was  the  first  to  apply  the  artificially  iodized 
fats  to  the  investigation  of  the  fat-splitting  power  of 
the  pancreatic  juice.  The  first  substance  used  was  iodi- 
pin,  but  it  was  found  that  the  iodine  present  in  this  sub- 
stance is  so  firmly  bound  that  even  normal  pancreatic 
juice  may  not  split  it.  He  finally  selected  monoiodo- 
behenate  of  calcium  or  sajodin  as  the  most  suitable  sub- 
stance. 

Sajodin  is  a  thin,  oily  liquid  containing  25  c/o  of 
iodine.  If  3  c.c.  of  this  substance  are  administered  by 
mouth  to  a  fasting  individual  and  the  urine  examined 
for  iodine  3  to  5  hours  later  the  reaction  will  be  nega- 
tive. If  the  same  substance  in  the  same  amount  is 
given  with  a  meal,  the  iodine  reaction  will  be  present. 
In  the  first  instance  no  pancreatic  secretion  has  been 
stimulated  to  appear  in  the  duodenum  and  consequently 
the  sajodin  is  not  split.  In  the  second  instance  the 
opposite  prevails. 

It  was  further  found  that  in  cases  of  icterus  no 
splitting  of  sajodin  takes  place  because  of  the  absence 
of  bile  salts  in  the  intestine,  which  are  necessary  to 
actuate  the  fat-splitting  ferment  and  to  stimulate  ab- 
sorption. 

Several  investigators  have  investigated  the  Winter- 
nitz test  and  the  question  has  been  made  the  subject 
of  a  thesis  by  Stegman.10  He  concludes  that  the  failure 
to  find  iodine  in  the  urine  3-5  hours  after  the  ingcstion 
of  3-5  c.c.  of  sajodin  with  a  meal,  is  indicative  of  lipo- 
lytic  pancreatic  insufficiency  in  most  cases,  and  that, 
in  combination  with  other  well-known  tests,  the  method 
of  Winternitz  may  be  regarded  as  of  considerable  cor- 
roborative value. 

10  Uebcr    eine    neue    Methode    tier    Pankreasfunktions    prufung 
Winternitz  Diagnostikum.     Dissertation  Otto  Stegman,  1911. 


Tests  of  Pancreatic  Function  153 

In  a  recent  inaugural  dissertation  upon  the  Winter- 
nitz  sajodin  test  by  Syring,11  this  author  finds  that 
without  exception  in  normal  cases  iodine  appears  in  the 
urine  in  3-5  hours  after  the  ingestion,  with  a  meal,  of  5 
c.c.  of  calcium  monoiodobehenate  (sajodin). 

The  question  as  to  its  real  value  in  determining  the 
existence  of  pancreatic  insufficiency  can  only  be  settled 
by  further  investigations. 

3.  Starch  Digestion  Test.  Identification  of  Undi- 
gested Starches  in  the  Stools  as  an  Evidence  of 
Pancreatic  Insufficiency 

The  presence  of  starch  in  the  stools  is  generally  un- 
derstood to  be  of  little  value  in  this  connection.  Nor- 
mally scattered  granules  of  undigested  starch  are  to  be 
found  and  can  be  easily  identified  under  the  microscope, 
when  stained  with  iodine  solution  (Lugol's),  which 
colors  them  blue.  Any  great  excess,  however,  may 
fairly  awaken  suspicion,  especially  if  there  is  persistent 
diarrhoea  and  the  condition  tends  to  be  permanent  or 
long  continued.  Under  these  circumstances  it  is  legiti- 
mate to  conclude  that  there  is  pancreatic  insufficiency. 

4-  Identification  of  Various  Ferments.  Tests  Where 
Examination  Is  Made  for  the  Pancreatic  Fer- 
ments Themselves  in  the  Excreta.  The  Meaning 
and  Interpretation  of  These  Results  in  Relation 
to  Estimating  the  Pancreatic  Function 

The  different  pancreatic  ferments  can  be  demon- 
strated by  proper  methods,  in  the  stomach  (after  an 
oil  meal),  in  the  urine,  and  feces. 

Einhorn,  Gross,  and  others  have  devised  special  ap- 
11  Ueber  die  Funktionsprufung  des  Pankreas.     Leipzig,  1913. 


154      Manual  of  Vital  Function  Testing  Methods 

paratus  for  obtaining  the  pancreatic  juice  directly  from 
the  duodenum.  Einhorn's  duodenal  tube  is  used  consid- 
erably in  this  country,  but  more  particularly  for  thera- 
peutic purposes. 

One  objection  which  urges  against  all  tests  for  tryp- 
sin  in  the  stools  is  that  erepsin,  a  ferment  coming  from 
the  mucous  membrane  of  the  small  intestine,  may  digest 
albumen,  etc.,  even  in  the  absence  of  trypsin.  The  ob- 
jection cannot  be  urged  against  the  gastric  estimations, 
and,  in  fact,  seems  to  be  exaggerated  even  when  applied 
to  fecal  analysis  methods. 

Demonstration  of  Trypsin  in  the  Stools. — Two 
methods  are  chiefly  used ;  the  Serum  Plate  method  and 
the  Casein  method. 

The  Serum  Plate  Method  of  Mutter  and  Schlecht.12 — 
Trypsin  acts  upon  the  surface  of  serum  agar  plates. 

Method.  One  drop  of  the  stool  obtained  by  a  laxa- 
tive (calomel  or  phenolphthalein)  is  placed  upon  a 
Loffler  serum  agar  plate  and  kept  at  a  temperature  of 
55°  to  60°  C.  for  6-12  hours  in  an  incubator. 

If  trypsin  is  found  in  the  stool  there  will  appear  a 
depression  or  hole  in  the  serum  due  to  digestion  by  the 
enzyme. 

Ordinary  diphtheria  culture  tubes  have  been  sug- 
gested by  Stadmiiller  as  being  sufficient  for  the  purpose 
of  the  test. 

This  test  is  simple  and  seems  to  be  rather  highly  re- 
garded (Brugsch,  Hirshberg,  etc.).  Other  practical 
methods  of  demonstrating  trypsin  in  the  feces  have  been 
devised.  Arthur  and  Hubert  add  a  2%  solution  of 
sodium  fluoride  to  the  stools,  also  fibrin,  and  incubate 
at  40°  for  24  hours.  Crystals  of  tyrosin  are  formed  if 
trypsin  be  present.  Abderhalden's  technique  has  also 
been  employed,  using  glycyl-tyrosin.  The  Miiller- 
12  Munch,  med.  Wchnschr.,  1908,  LV,  225. 


Tests  of  Pancreatic  Function  155 

Schlecht  method  is  sufficient,  however,  and  much  more 
simple. 

For  a  quantitative  variation  of  the  serum  agar  plate 
method  of  stool  examination  for  trypsin,  put  in  one  part 
of  the  plate  undiluted  feces  and  in  orderly  sequence 
in  other  portions  of  the  plate  use  dilutions  of  the  feces 
1:10,  1 :  20,  1 :  100,  1 :  200,  and  note  which  still  forms 
indentation.  If  the  stools  are  fatty  the  fat  should  be 
extracted  with  ether. 

The  Casein  Method  of  Demonstrating  Trypsin  in  the 
Stools. — Casein  in  alkaline  solution  is  precipitated  by 
dilute  acetic  acid.  If  casein  is  digested  by  trypsin  it 
will  no  longer  give  the  precipitation  reaction  with  dilute 
acetic  acid.  This  is  the  foundation  of  a  test  devised 
by  Gross.13 

In  Gross'  method  the  feces  are  mixed  with  an  alkaline 
solution  of  casein — .1%  casein,  .1%  sodium  carbonate. 
Various  quantities  of  the  filtered  feces  are  added  to  the 
casein  solution,  incubated  for  an  hour  and  tested  with 
dilute  acetic  acid.  (v.i. ) 

Mette's  tubes  are  also  sometimes  used  in  testing  for 
the  presence  of  trypsin.  They  consist  of  glass  tubes 
about  1  or  2  mm.  in  diameter,  containing  coagulated  egg 
albumen.  These  are  suspended  in  the  dilute  feces  or 
other  solution  to  be  tested  for  a  fixed  time  and  the 
amount  of  albumen  digested  off,  measured.  The 
strength  of  the  ferment  will  be  proportional  to  the 
square  of  the  length  digested. 

Technic  of  Gross'  Quantitative  Test  for  Trypsin. — 
Prepare  a  .19c  solution  of  casein  by  adding  1  gm.  of 
pure  casein  (Merck)  and  1  gm.  of  sodium  carbonate  to 
1000  c.c.  of  chloroform  water.  Place  in  a  flask  and 

13  Arch.  f.  Exper.  Path,  und  Pharm.,  1907,  LVIII,  157;  also 
Deutsch.  med.  Wchnschr.,  1909,  XXXV,  1706. 


156      Manual  of  Vital  Function  Testing  Methods 

allow  to  stand  for  24  hours,  after  which  the  solution 
is  shaken  vigorously. 

Five  gms.  of  feces  are  placed  in  a  mortar.  Add  45 
c.c.  of  \c/o  solution  of  sodium  carbonate.  Titrate 
thoroughly  and  filter.  The  first  cloudy  portion  of 
filtrate  is  discarded.  The  second  is  used. 

To  each  of  six  reagent  glasses  marked  for  identifica- 
tion add  10  c.c.  of  the  casein  solution.  With  graduated 
pipette  add  respectively  1  gm.,  .5  gm.,  .25  gm.,  .2  gm. 
and  .1  gm.  of  filtered  feces  to  specimen  and  mix  thor- 
oughly. Place  all  in  incubator,  adding  to  each  3  drops 
of  1%  acetic  acid.  Specimens  in  which  the  casein  are 
digested  (presence  of  trypsin)  will  remain  clear;  others 
are  cloudy. 

In  normal  stools,  glasses  1  to  3  are  clear,  4  to  6 
cloudy.  A  trypsin  unit  equals  the  amount  of  feces 
which  digests  10  c.c.  of  starch  casein  solution.  If  .33 
gm.  feces  which  is  diluted  tenfold  digests  10  c.c.  of 
casein  solution,  there  are  30  trypsin  units,  which  is  nor- 
mal. In  clinical  work,  disease  of  the  pancreas  may  be 
suspected  when  no  trypsin  or,  at  most,  10  units  are 
found  in  examination  of  the  feces. 

Demonstration  of  Trypsin  in  the  Stomach  Contents. 
Method  of  Boldyreff-Volhard.14 — Boldyreff  noted  in 
1904  in  Pawlow's  Institute  that  feeding  olive  oil  to  dogs 
caused  regurgitation  of  duodenal  contents  into  the 
stomach.  Volhard  15  applied  the  principle  to  the  clinic. 

A  breakfast  of  200  c.c.  of  olive  oil  is  given  by  stom- 
ach tube  or  250  c.c.  of  cream  may  be  substituted,  the 
latter  being  swallowed.  Half  a  tcaspoonful  of  magnesia 
usta  are  given  just  prior  to  the  meal  and  is  repeated 

"Ccntrbl.   f.   Physiol.,  1904,  XVIII.  457;   also   Zentbl.   f.  Phys. 
und  Path.  d.  Stoffw.,   1909,  III,  209. 

15  Munch,  med.   Wchnschr.,  1907,  LIV,  403. 


Tests  of  Pancreatic  Function  157 

twenty  minutes  afterward.  This  is  to  prevent  acidifica- 
tion. At  the  end  of  45  to  60  minutes,  the  stomach  con- 
tents are  removed  by  tube.  Usually  a  liquid  is  obtained 
which  tends  to  separate  into  two  layers,  the  lower  one 
containing  the  duodenal  juice. 

The  presence  of  trypsin  can  be  demonstrated  by  the 
Gross  casein  test  described  above  or  by  that  of  Arthur 
Hubert,16  previously  mentioned,  the  details  of  which 
follow : 

Fresh  fibrin  obtained  from  horse  blood  by  whipping 
and  washing  the  coagulum  is  covered  with  2%  solution 
of  sodium  fluoride  and  kept  for  24  hours  at  40°  C., 
then  filtered. 

The  fluid  to  be  examined  is  diluted  with  equal  volume 
of  2%  sodium  fluoride  solution,  and  one  volume  of  this 
dilution  is  added  to  two  or  three  volumes  of  the  fibrin 
solution  and  digested  at  40°  for  some  hours.  Crystals 
or  crusts  of  tyrosin  form  on  the  wall  of  the  vessel. 

According  to  Sahli  trypsin  can  qualitatively  be  most 
easily  demonstrated  by  digesting  in  alkaline  fluid  at 
incubator  temperature  a  flake  of  fibrin  stained  with 
magenta  red.  The  fibrin  becomes  digested  and  dissolved 
and  the  fluid  is  colored  red. 

Stadmiiller  mentions  a  simple  qualitative  test  devised 
by  Von  Oefele.  A  few  drops  of  Fehling's  alkali  solution 
with  a  few  drops  of  a  1-1000  solution  of  casein  are 
added  to  a  .07%  copper  sulphate  solution  and  .1% 
sodium  carbonate.  The  mixture  is  incubated  at  55°. 
To  5  c.c.  of  this,  in  a  warm  test  tube,  are  added  five 
drops  of  the  fluid  (intestinal  juice)  to  be  tested,  the 
whole  being  shaken.  If  trypsin  is  present  the  solution 
which  at  first  is  blue  or  green  if  bile  is  present  becomes 
red-violet  or  rose  color. 

"Archiv.  de  Physiol.,  1894,  622. 


158      Manual  of  Vital  Function  Testing  Methods 


5.     Estimation  of  Diastatic  and  Lipolytic  Ferment  in 
the  Feces  as  a  Measure  of  Pancreatic  Function 

The  results  obtained  by  a  study  of  the  diastase  con- 
tent of  the  stool  should,  provided  all  controllable  fac- 
tors in  performing  the  test  are  standardized,  give  val- 
uable information  concerning  the  functional  integrity 
of  the  pancreas.  The  physiological  basis  upon  which 
the  test  is  founded  is,  that  practically  the  whole  amount 
of  diastatic  ferment  found  in  the  feces  is  of  pancreatic 
origin,  i.e.,  provided  certain  possible  sources  of  error 
are  understood  and  obviated  (Wohlgemuth). 

Several  satisfactory  methods  for  estimating  diastase 
in  the  feces  have  been  devised,  chief  of  which  are  those 
of  Wohlgemuth  17  chiefly  used  in  Germany ;  that  of 
Durand,18  chiefly  used  in  France  and  England,  and  that 
of  Brown,19  chiefly  used  in  the  United  States.  The 
methods  of  Durand  and  Brown  will  be  described. 

Durand's  Method  of  Estimating  Diastase  in  the 
Feces, — One  c.c.  of  the  total  diluted  feces  is  added  to 
50  c.c.  of  starch  solution  (1c/c  starch  and  2%  decinor- 
mal  HC1).  The  tubes  are  incubated  for  half  an  hour 
at  39.5°  C.  and  digestion  is  then  stopped  with  three 
drops  of  strong  soda  solution.  The  sugar  formed  is 
estimated  quantitatively  with  Fehling's  solution. 

Ten  c.c.  Fehling's  solution  is  reduced  by  .0124  gm. 
of  sugar.  If  x  be  the  number  of  c.c.  of  the  incubated 
mixture  used  to  reduce  the  Fehling's  solution,  the 
amount  of  sugar  present  in  the  51  c.c.  of  the  mixture 

.„   ,        .0124  X  51  . 

will  be —  or,  in  the  whole  amount   or   the 

x 

"Biochem.  Zeitsch.,  1908,  IX,  I;  also  ibid.,  1909,  XXX,  432. 
"Archiv.  des  Mai.  d.  Appnr.  Digest.,  1911,  V,  76. 
19  Johns  Hopkins  Hosp.  Bull.,  1914,  XXXV,  200. 


Tests  of  Pancreatic  Function  159 

.0124  X  51  X  20,000.  „,. 

teces  (obtained  as  below), ims 

x 

figure  is  multiplied  by  two  to  give  units  of  grams  of 
sugar  formed  in  the  hour.  The  normal  limits  are  1500- 
2000  units. 

The  feces  for  the  test  are  obtained  as  follows:  The 
patient  is  well  purged  12  hours  after  his  last  meal.  He 
is  then  given  %  liter  of  milk  and  45  minutes  later  50 
grams  sodium  sulphate  in  water,  and  one-half  hour  after 
this  a  glass  of  vichy.  The  feces  of  the  next  3^/2  hours 
are  passed  into  a  vessel  containing  ice.  They  are  then 
diluted  with  water  to  20  liters  and  tested  as  above. 

Technic  of  Brown's  Test. — The  patient  is  given  a 
high  enema  the  night  before.  The  evening  meal  should 
be  very  light.  At  7  A.  M.  the  next  morning  750  c.c.  of 
milk  are  given.  At  7:30  and  again  at  8:30  A.  M.  1/2 
ounce  of  Epsom  salts  are  taken.  At  8 :30  a  glass  of 
water  containing  1/4  teaspoonful  of  sodium  bicarbonate 
is  swallowed. 

All  stools  up  to  2  P.  M.  are  saved  in  a  vessel  con- 
taining 2  ounces  of  toluol  which  is  kept  in  a  cool  room 
or  on  ice.  If  less  than  400  c.c.  of  stool  are  obtained 
an  enema  of  a  pint  of  water  is  given.  The  average 
quantity  collected  up  to  2  P.  M.  will  be  from  400  to 
1100  c.c.  usually. 

The  stool  should  be  examined  as  soon  as  possible 
after  2  P.  M.  Dilute  the  amount  up  to  3000  c.c.  with 
normal  salt  solution,  stir  the  whole  amount  until  abso- 
lutely homogeneous.  Centrifugalize  a  portion  for  5 
minutes  and  use  the  supernatant  fairly  clear  fluid  for 
testing. 

Diminishing  amounts  of  the  fluid  are  put  into  a  series 
of  tubes,  1.8  c.c.  in  the  first,  1.6  c.c.  in  the  second,  1.4 
c.c.  in  the  third,  1.2  c.c.  in  the  fourth,  1  c.c.  in  the 


160      Manual  of  Vital  Function  Testing  Methods 

fifth,  .8  c.c.  in  the  sixth,  .6  c.c.  in  the  seventh,  .4  c.c.  in 
the  eighth,  .2  c.c.  in  the  ninth,  .1  c.c.  in  the  tenth,  .05 
c.c.  in  the  eleventh  and  .025  c.c.  in  the  twelfth.  Bring 
the  fluid  in  each  of  the  tubes  up  to  2  c.c.  with  normal 
salt  solution.  If  the  test  shows  a  negative  reading  in  the 
first  tube  or  if  a  low  reading  is  expected,  a  supplemen- 
tary set  of  tubes  is  prepared  containing  respectively,  2 
c.c,  3  c.c.,  4  c.c.,  and  5  c.c.  centrifugalized  mixture. 

In  each  of  the  tubes  is  added  2  c.c.  of  1%  solution 
of  soluble  starch  (Kahlbaum)  and  the  tubes  are  incu- 
bated at  38°  C.  in  water  bath  i/o  hour,  then  cooled  by 
adding  a  little  tap  water  and  by  holding  them  under 
the  cool  tap.  They  are  then  quickly  tested  with  a  few 
drops  of  one  tenth  normal  iodine  solution.  The  limit 
is  held  to  be  that  tube  before  the  one  in  which  the  first 
definite  blue  color  appears. 

Demonstration  of  Lipolytic  Ferment. — Two  simple 
tests  for  the  presence  of  lipolytic  ferment  may  be  men- 
tioned. These  are  the  Grutzner-Gamgee  20  method  and 
the  von  Oefele  21  method. 

The  first  is  as  follows :  An  emulsion  of  ten  parts  of 
oil,  five  parts  of  gum  and  thirty-five  parts  of  water  is 
prepared.  A  neutral  solution  of  litmus  is  made  up 
which  in  test  tubes  of  12  mm.  diameter  appears  violet 
against  white  paper.  Ten  c.c.  of  litmus  solution  and 
5  drops  of  the  emulsion  are  placed  in  several  of  these 
tubes  and  increasing  quantities,  2,  4,  8,  16,  32  drops, 
of  the  fluid  to  be  tested  are  added  to  the  successive  test 
tubes.  These  are  put  in  a  water  bath  at  37°  C.,  and  af- 
ter a  short  time  the  tubes  are  compared.  If  any  fat- 
splitting  ferment  is  present  the  color  of  the  fluid  will 
have  turned  redder  the  larger  the  amount  of  solution 
added. 

20  Quoted  by  Stadmiiller,  loc.  cit. 

21  From  Sahli's  Diagnostic  Methods,  421. 


Tests  of  Pancreatic  Function  161 

Von  Oefelc's  method  of  demonstrating  steapsin  is  as 
follows :  sweet  butter  is  melted  and  the  resulting  clear 
fat  mixed  with  an  equal  proportion  of  a  \cfo  aqueous 
solution  of  potassium  carbonate  and  some  phenolphtha- 
lein,  and  then  titrated  with  a  soda  solution  until  there  is 
a  red  tint.  This  liquid  is  heated  in  the  incubator  to 
55°  C.  and  5  c.c.  of  it  well  shaken  in  a  warm  test  tube 
with  5  drops  of  intestinal  juice.  In  the  presence  of  a 
normal  amount  of  steapsin  the  red  tint  will  disappear 
in  from  2  to  5  minutes.  According  to  the  rapidity  of 
the  discoloration  the  quantity  of  actual  steapsin  can 
be  estimated. 

C.        TESTS    FOR    PANCREATIC    FUNCTION    WHICH    CONCERN 

THE   INTERNAL,   OR   METABOLIC    FUNCTION   OF 

THE    ORGAN 

All  the  functional  tests  of  pancreatic  activity  which 
have  been  described  have  related  to  the  external  secre- 
tion with  its  enzymes,  which  is  poured  out  thro  the 
pancreatic  duct  and  the  ampoule  of  Vater  into  the 
small  intestine. 

There  is,  however,  another  phase  to  the  question  of 
functional  deficiency  of  the  pancreas  and  this  relates 
to  its  internal  secretion,  which  in  some  mysterious  or 
quite  unknown  manner  presides  over  the  mobilization 
and  destruction  of  sugar  in  the  body.  When  the  in- 
ternal secreting  function  of  the  pancreas  is  lowered, 
the  power  of  assimilation  of  carbohydrates  is  reduced 
and  when  a  certain  limit  is  reached  a  hyperglycemia 
results  which  tends  at  a  certain  point  to  manifest  itself 
by  the  elimination  of  sugar  in  the  urine,  glycosuria, 
diabetes. 

There  are  three  functional  tests  which  concern  par- 
ticularly the  internal  function  of  the  pancreas.  These 
are: 


162      Manual  of  Vital  Function  Testing  Methods 

1.  The  Cammidge  Reaction. 

2.  Loewi's  Pupillary  Reaction. 

3.  Provocative  Alimentary  Glycosuria. 

1.     The  Cammidge  Pancreatic  Reaction 

There  is  still  much  dispute  as  to  just  what  position 
the  reaction  holds  in  the  clinical  diagnosis  of  pancreatic 
function. 

The  original  Cammidge  reaction  consisted  of  two 
parts  or  analyses  which  were  known  as  A  and  B  tests. 
It  was  held  that  the  presence  of  a  pancreatic  lesion 
and  even  its  nature  could  be  determined  by  these  tests. 
The  original  theory  upon  which  the  test  was  based  was 
about  as  follows.  If  there  is  a  real  pancreatic  lesion, 
the  pancreatic  juice  will  escape  into  the  parenchyma 
of  the  organ  and  lead  to  fat  necrosis  with  splitting 
of  neutral  fat  into  fatty  acids  and  glycerine. 

The  fatty  acids  will  remain  in  the  necrotic  areas 
and  the  glycerine  will  be  absorbed  into  the  blood  and 
excreted  by  the  urine.  The  Cammidge  test  was  de- 
vised to  demonstrate  the  presence  of  glycerine  in  the 
urine  by  the  presence  of  glycerosazone  crystals. 

The  original  theory  was  subsequently  modified  and 
the  two  original  tests  were  abandoned  and  replaced 
by  one  process  known  as  the  C  test.  The  present 
theory  of  the  Cammidge  test  is  this.  The  crystals 
produced  in  the  test  when  positive,  result  from  the 
presence  in  the  urine  of  a  sugar  complex  which  upon 
hydrolysis  with  HC1  yields  a  substance  giving  a  pentose 
reaction.  The  crystals  of  a  positive  reaction  are  be- 
lieved to  be  pentosazone. 

The  pancreas  contains  four  or  five  times  as  much 
pentose  as  any  other  organ  in  the  body  and  conse- 
quently when  any  disintegration  of  pancreatic  tissue 


Tests  of  Pancreatic  Function  163 

takes  place  as  a  result  of  disturbance  or  disease  of  the 
organ,  crystals  of  pentosazone,  the  Cammidge  crystals 
will  be  demonstrated  in  the  urine.  Neither  a  mere 
blocking  of  the  pancreatic  secretions  nor  a  pure  fibrosis 
of  the  organ  will  produce  a  positive  reaction.  It  is 
usually  held  as  Cammidge  himself  believes  that  a  posi- 
tive reaction  is  evidence  of  active  degeneration  such 
as  occurs  in  acute  or  chronic  pancreatitis.  A  negative 
reaction  contraindicates  active  degeneration  but  does 
not  exclude  old  pancreatitis  nor  malignant  disease  of 
the  pancreas.  In  fact,  in  75%  of  malignant  cases  the 
reaction  is  negative.  But  the  test  is  not  always  posi- 
tive even  in  pancreatitis  and  a  negative  test  does  not 
definitely  exclude  pancreatitis.  The  results  must  al- 
ways be  taken  in  conjunction  with  clinical,  urinary  and 
fecal  findings.  The  test  is  not  considered  generally  by 
pathologists  or  clinicians  as  having  great  practical 
value  in  diagnosis.  But  when  positive  it  constitutes  an 
interesting  abnormality  which  seems  to  be  connected 
in  some  rather  cryptic  or  obscure  manner  with  dis- 
turbances of  the  pancreatic  function. 

Teclinic  of  the  Cammidge  Test. — Filter  a  portion  of 
a  24-hour  specimen  of  urine. 

Test  for  Albumen. — If  albumen  is  present  in  amount 
more  than  a  trace,  measure  out  50  c.c.  of  filtrate  and 
add  a  few  drops  of  acetic  acid,  boil,  cool,  filter  and 
make  up  to  50  c.c. 

Test  for  Sugar. — Either  Fehling's  or  Nylander's 
test  is  performed.  The  result  must  be  absolutely  nega- 
tive. If  there  is  any  reduction  on  standing  about  50 
c.c.  of  the  albumen  free  urine  must  be  mixed  with 
yeast  fermented  for  12  to  2-1  hours  and  filtered. 

Stage  I.  Measure  20  c.c.  of  the  clear  albumen  and 
sugar  free  filtrate  into  a  small  flask  with  an  in- 
verted filter  funnel  placed  in  its  mouth  as  a  condenser. 


164      Manual  of  Vital  Function  Testing  Methods 

Add  1  c.c.  of  strong  HC1.  Boil  on  sand  bath  for  10 
minutes  from  commencement  of  ebullition.  The  boil- 
ing should  not  be  too  vigorous  and  the  flame  should 
be  turned  low  for  the  greater  part  of  the  time. 

Stage  II.  Cool  under  the  tap.  Make  up  contents 
to  20  c.c.  with  distilled  water.  Slowly  add  4  gms.  of 
lead  carbonate ;  shake  gently  at  first  and  more  thor- 
oughly later.  Stand,  and  shake  occasionally  until  no 
more  gas  comes  off.  Filter  through  a  paper  moistened 
with  distilled  water. 

Stage  III.  Add  4  gms.  of  powdered  tribasic  acetate. 
Shake  thoroughly  for  some  minutes  and  allow  to  stand. 
Filter  thro  a  moistened  filter  paper. 

Stage  IV.  To  the  clear  and  almost  colorless  filtrate 
add  2  gms.  of  powdered  sodium  sulphate,  shake  thor- 
oughly for  several  minutes.  Bring  slowly  up  to  the 
boiling  point  on  a  sand  bath,  shaking  from  time  to 
time.  The  excess  of  lead  is  removed  at  this  stage  and 
it  is  important  that  the  shaking  and  heating  should 
be  done  carefully. 

Stage  V.  Cool  under  the  tap  and  filter.  Measure 
10  c.c.  of  clear  filtrate.  Make  up  to  18  c.c.  with  dis- 
tilled water.  Add  8  gms.  of  phenyl-hydrazine  hydro- 
chlorate,  2  gms.  powdered  sodium  acetate  and  1  c.c. 
of  50^?  acetic  acid. 

Boil  in  a  flask  with  a  funnel  condenser  on  the  sand 
bath  for  10  minutes  from  the  commencement  of  ebulli- 
tion. Do  not  boil  too  vigorously.  Filter  hot  through 
a  filter  paper  moistened  with  boiling  distilled  water 
into  a  15  c.c.  measure.  Should  the  filtrate  fail  to  reach 
the  15  c.c.  mark  make  up  to  15  c.c.  with  hot  distilled 
water.  Stand  for  from  4  to  5  hours  or  longer  at  room 
temperature  or  in  ice  chest. 

Examine  the  filtrate  for  the  appearance  solubility 
and  amount  of  crystal  formation. 


Tests  of  Pancreatic  Function  165 

The  typical  crystals  examined  under  the  microscope 
are  of  the  osazone  type  and  more  circular  and  tuft-like 
than  glucosazone  crystals.  Run  under  the  cover  slip 
33%  H2S04;  the  crystals  should  dissolve  in  10-15  sec- 
onds. The  crystals  have  to  be  distinguished  from  the 
coarse  yellow  needles  which  may  be  deposited  if  the  ex- 
cess of  lead  was  not  removed  in  Stage  IV.  In  a  strongly 
positive  reaction  the  deposit  of  crystals  may  occupy 
half  the  bulk  of  the  filtrate.  In  a  completely  negative 
reaction  the  filtrate  remains  clear. 

*2.     Loewi's  Pupillary  Symptom  or  Test  of  Pancreatic 
Insufficiency 

In  1908  Loewi  22  made  the  observation  that  after  re- 
moval of  the  pancreas  in  certain  animals,  the  instilla- 
tion of  adrenalin  into  the  eye  will  cause  dilatation  of  the 
pupil.  Ordinarily  the  instillation  of  adrenalin  into  the 
eye  does  not  cause  dilatation  altho  intravenous  injec- 
tion will  do  so.  Loewi  attributed  the  mydriasis  fol- 
lowing instillation  to  increased  excitability  of  the  sym- 
pathetic system  brought  about  by  the  removal  of  the 
inhibitory  effect  of  the  pancreatic  internal  secretion. 

From  this  fact  it  was  thought  that  a  mydriasis  in  man 
following  local  instillation  of  adrenalin  would  indicate 
pancreatic  internal  insufficiency,  provided  hyperthy- 
roidism  or  Graves  disease  did  not  exist. 

According  to  Sladden  23  this  test  has  given  interest- 
ing and  encouraging  results  and  should  not  be  dis- 
missed with  the  comparatively  scant  attention  it  has 
received  lately. 

The  technic  of  the  test  is  extremely  simple  since  it 
consists  merely  of  dropping  into  the  conjunctional  sac 

22  Archiv.  of  Exper.  Path,  and  Pharm.,  1908,  LIX,  83. 
"Quart.  Jour,  of  Med.,   1913-14,  VII,  455. 


166      Manual  of  Vital  Function  Testing  Methods 

a  few  drops  of  a  1 :  1000  solution  of  adrenalin  and  ob- 
serving the  effects  upon  the  pupil. 

3.     Spontaneous  and  Provocative  Alimentary  Glyco- 
suria  in  Their  Relation  to  Pancreatic  Function 

The  intimacy  of  relationship  between  the  pancreas 
and  control  of  the  carbohydrate  metabolism  is  close 
and  undisputed,  but  what  particular  cells  of  the  pan- 
creas are  concerned  or  just  what  the  mechanism  of  the 
control  may  be  is  very  imperfectly  understood.  Glyco- 
suria  is  usually  present  in  many  of  the  more  serious 
pancreatic  diseases,  but  glycosuria  is  by  no  means  an 
infallible  index  of  either  the  extent  or  the  nature  of 
the  pathological  processes.  In  many  cases  of  pan- 
creatic disease,  however,  glycosuria  does  not  appear 
(e.g.  many  cases  of  chronic  pancreatitis,  carcinoma, 
etc.).  According  to  Cammidge  the  presence  of  glycosu- 
ria means  only  a  one  to  three  chance  that  the  pancreas 
is  diseased,  and  in  case  of  pancreatic  disease  about  one 
in  fourteen  shows  sugar  in  the  urine.  The  truth  is 
well  expressed  by  Sladden  when  he  says,  "viewed  arith- 
metically, glycosuria  is  not  a  sign  of  great  diagnostic 
value."  If,  however,  glycosuria  either  spontaneous  or 
provocative  be  present  together  with  other  confirmatory 
evidence  of  pancreatic  disease  the  symptom  then  ac- 
quires a  greater  value. 

It  must  be  remembered  that  the  liver  is  also  concerned 
to  a  very  important  and  intimate  extent  with  carbo- 
hydrate metabolism,  and  tests  for  alimentary  glycosuria 
have  long  been  employed  with  a  view  of  estimating  the 
functional  integrity  of  that  organ.  Under  a  previous 
chapter  these  tests  have  been  given  and  discussed. 

It  must  be  perforce  admitted  that  the  question  of 
applying  the  so-called  carbohydrate  tests  for  provoca- 


Tests  of  Pancreatic  Function  167 

tive  glycosuria  to  the  elucidation  of  pancreatic  func- 
tion is  one  which  for  the  present  must  be  left  open. 

It  would  appear  rational  to  assume  that  the  pres- 
ence of  glycosuria  after  the  provocative  tests  indicates 
either  hepatic  or  pancreatic  insufficiency  or  both,  and 
such  tests  are  never  in  themselves  sufficient  to  elucidate 
the  problems  involved,  but  where  they  are  corroborated 
by  other  more  specific  evidences  of  insufficiency,  they 
assume  an  importance  in  diagnosis  of  no  mean  value, 
an  importance  which  is  entirely  lacking  to  them  when 
interpreted  alone. 

General  Conclusions  Concerning  the  Tests  for 
Pancreatic  Insufficiency 

It  is  certainly  true  that  no  one  functional  test  of 
pancreatic  activity  so  far  devised  constitutes  an  abso- 
lute or  pathognomonic  sign  of  disease  of  this  organ. 
It  is  quite  natural  that  this  should  be  so  in  view  of  the 
manifold  functions  of  the  pancreas. 

In  other  words  it  is  often  a  very  difficult  question 
to  determine  in  a  given  case  whether  the  pancreas 
is  diseased  or  insufficient  at  all,  much  less  to  make  out 
by  means  of  the  most  complete  and  comprehensive 
semeiological  study  the  precise  nature  and  extent  of 
the  pathological  processes. 

The  whole  subject  of  pancreatic  clinical  pathology 
and  diagnosis  and  that  of  tests  for  functional  activity 
of  the  organ  is  in  its  infancy. 

Nevertheless  the  value  of  those  functional  tests  so 
far  devised  is  considerable  and  it  is  the  duty  of  clini- 
cians to  apply  them  in  practice  to  such  an  extent  that 
their  individual  and  collective  worth  or  lack  of  worth 
may  be  definitely  determined. 


CHAPTER  IV 
TESTS  OF  HEART  FUNCTION 

GENERAL,     CONSIDERATIONS 

IN  recent  times  a  considerable  transformation  has 
occurred  in  the  viewpoint  of  clinicians  toward  the 
cardiopathies  and  cardiac  pathology.  A  few  years 
ago  all  cardiopathology  was  discussed  in  terms  of 
anatomical  lesion.  The  chief  interest  lay  in  the  exact 
localization  and  delimitation  of  the  lesion.  The  ten- 
dency at  the  present  is  to  bring  more  and  more  into 
the  foreground  the  idea  of  functional  capacity  of  the 
organ.  Recent  studies  in  cardiac  physiology  and 
pathology  have  shown  that  the  fundamental  factor  is 
the  muscle  itself  rather  than  its  innervation  as  was  be- 
fore believed.  It  has  been  likewise  shown  that  the  func- 
tion of  the  cardiac  muscle  is  a  complex  one  and  that 
at  least  five  subdivisions  of  function  may  be  made 
(Englemann).  These  may  be  enumerated.  The  heart 
muscle  possesses  the  power  of  originating  contractile 
impulses  (impulse  formation,  chronotropic  function)  ; 
it  possesses  the  faculty  of  susceptibility  to  the  receipt 
of  these  functions  (excitability,  irritability,  bathmo- 
tropic  function)  ;  it  is  endowed  by  means  of  the  conduct- 
ing system  of  fibers  including  a  histological  differenti- 
ated tissue,  the  bundle  of  His  with  power  to  transmit 
these  impulses  from  the  point  of  their  formation,  the 

168 


Tests  of  Heart  Function  169 

sino-auricular  node  to  the  cardiac  muscular  fibers  (the 
conducting  function,  conduction,  dromotropic  func- 
tion) ;  it  possesses  the  fundamental  power  of  contrac- 
tion (contractility,  inotropic  function),  and  finally,  the 
muscle  possesses  that  vital  function  by  which  it  nor- 
mally refuses  to  dilate  beyond  a  certain  point  (tonic- 

ity). 

A  perfect  method  of  estimating  cardiac  function 
would  be  one  in  which  all  these  five  functions  of  the 
cardiac  muscle  could  be  separately  measured.  The 
function  of  the  entire  organ  would  be  then  their  arith- 
metical sum,  if  all  possessed  some  degree  of  integrity 
or  their  algebraic  sum  if  certain  of  them  were  below  a 
normal  point  which  might  be  diagrammatically  repre- 
sented by  zero.  But  as  a  matter  of  fact  we  are  far 
from  being  able  to  accomplish  such  an  estimate  of 
cardiac  function  at  the  present  time. 

There  are  many  instances,  however,  in  which  a  care- 
ful physical  examination  of  the  organ  together  with 
the  use  of  special  methods  of  cardiac  investigation 
which  have  come  into  use  in  recent  years  (sphygmo- 
graph,  electrocardiograph,  sphygmodynamometer,  the 
X-ray)  will  enable  the  physician  to  conclude  that  one 
or  more  of  the  five  functions  of  the  cardiac  muscle  are 
deficient. 

When  some  or  all  of  these  functions  have  become 
so  insufficient  and  incompetent  that  the  occurrence  of 
heart  failure  (asystole)  is  imminent,  the  symptoms 
of  the  condition  (cyanosis,  decompensation,  edema, 
signs  of  venous  congestion)  become  so  patent  and  evi- 
dent that  the  presence  of  cardiac  insufficiency  is  simple 
to  recognize  from  a  study  of  the  physical  signs  and 
the  symptoms. 

This  stage  of  true  insufficiency  may  be  called  a  ter- 
minal stage  of  the  cardiopathies  no  matter  what  the 


170      Manual  of  Vital  Function  Testing  Methods 

anatomical  lesion  may  be  in  a  given  case.  This  stage 
is  known,  however,  to  be  preceded  by  a  long  period  of 
latency  in  which  cardiac  insufficiency,  if  it  is  present, 
cannot  be  so  easily  discovered  and  has  to  be  looked 
for  in  order  to  be  recognized. 

It  is  the  desire  of  the  clinician  to  increase  his  powers 
of  observation,  to  so  lengthen  as  it  were  his  cardiac 
vista,  that  he  may  be  enabled  to  recognize  the  earliest 
signs  of  cardiac  incompetency.  It  is  for  this  very  evi- 
dent reason  that  tests  for  estimating  the  integrity  of 
heart  functions  have  been  devised.  As  yet  no  one  of 
them  has  succeeded  in  providing  an  entirely  adequate 
means  of  obtaining  this  much  to  be  desired  end,  never- 
theless several  interesting  and  valuable  methods  have 
been  developed.  The  work  of  the  past  gives  promise  of 
future  developments  and  improvements  in  this  extreme- 
ly important  domain  of  functional  diagnosis. 

To  Rosenbach  is  generally  given  the  credit  of  in- 
sisting upon  the  necessity  of  devising  proper  tests 
by  which  the  functional  integrity  of  this  most  im- 
portant organ,  the  heart,  might  be  measured. 

The  various  methods  of  testing  the  cardiac  func- 
tion may  be  divided  into  a  few  classes.  The  first  and 
largest  group  includes  those  tests  which  depend  upon 
the  reaction  of  the  heart  muscle  to  various  types  of 
exertion  active  or  passive.  There  is  a  second  and 
much  smaller  group  based  upon  the  behavior  of  the 
heart  to  reflex  stimulation.  A  third  and  extremely 
insignificant  group  includes  but  one  test,  based  upon 
the  supposition  that  sodium  chloride  elimination  is 
effected  by  cardiac  insufficiency.  A  fourth  group  in- 
cludes modern  clinical  and  instrumental  methods  of 
investigating  cardiovascular  conditions  so  far  as  they 
are  concerned  with  the  question  of  elucidating  heart 
functional  power. 


Tests  of  Heart  Function  171 

The  following  synopsis  shows  how  the  various  tests 
are  to  be  placed  in  the  four  categories  above  men- 
tioned. 

I.  Reaction  to  muscular  exertion  active  or  passive 
as  a  basis  for  estimating  cardiac  function. 

1.  The  staircase  test. 

2.  Graupner's  test. 

3.  Mendelsohn's  test. 

4.  Katzenstein's   test. 

5.  Herz's  self-checking  test. 

6.  Gymnastic  resistance  test. 

7.  The  Russian  test — "Holding  the  breath"  test. 

8.  The  Venous  pressure  test. 

II.  Application   of  cardiac   reflex   estimations  in  de- 
termining heart  function. 
Merklen's  test. 

III.  Estimation  of  sodium  chloride  elimination  as  a  test 
of  cardiac  sufficiency. 
Vaquez-Digne  test. 

IV.  Modern  clinical  and  instrumental  methods  of  in- 
vestigating cardiovascular  conditions :  their 
applicability  to  estimating  cardiac  function. 

1.  The  sphygmomanometer  as  an  index  of  cardiac 

function. 

2.  Rontgenoscopy  and  Rontgenography  as  indices 

of  cardiac  function. 

3.  Sphygmocardiography     and    electrocardiogra- 

phy ;    their    relation    to    cardiac    functional 
capacity. 

I.        REACTION    TO    MUSCULAR    EXERTION    ACTIVE    OR    PAS- 
SIVE AS  A  BASIS   FOR   ESTIMATING  CARDIAC   FUNCTION 

The  majority  of  the  methods  so  far  suggested  for 
estimating  heart  functional  power  have  consisted  in 


172      Manual  of  Vital  Function  Testing  Methods 

the  subjection  of  the  patient  to  a  certain  measured 
degree  of  physical  exertion  followed  by  the  systematic 
observation  of  the  phenomena  produced  by  the  exer- 
tion as  compared  with  conditions  carefully  ascertained 
prior  to  the  beginning  of  the  test. 

All  these  methods,  however,  have  the  common  objec- 
tion that  the  same  work  prescribed  to  different  indi- 
viduals, will  under  normal  circumstances  produce  quite 
different  results,  according  to  certain  circumstances, 
among  which  are  the  size  and  general  muscular 
strength  of  the  individual,  the  usual  mode  of  life  with 
respect  to  physical  exertion,  the  condition  of  the  nerv- 
ous system,  etc.  The  result,  therefore,  of  exertion 
tests  may  not  always  be  comparable  even  in  healthy 
persons.  If  these  factors  can  be  properly  estimated 
and  provided  for  the  exertion  tests  are  rendered  more 
certain  and  hence  more  useful. 

Herz  has  emphasized  the  fact  that  the  cardiac  phe- 
nomena produced  by  exertion  tests  are  varied  by  the 
type  of  effort  attempted:  whether,  for  example,  the 
movements  are  rhythmical  and  gymnastic,  whether  they 
are  resisted  or  not,  and  especially  whether  the  muscular 
groups  called  into  play  are  weaker  or  stronger.  A 
much  higher  rise  of  blood  pressure  is  produced  by  the 
effort  attempted  by  a  weaker  set  of  muscles  than  the 
same  operation  performed  by  a  stronger  set.  Grebner 
and  Grunbaum  have  contended  that  the  increase  in 
blood  pressure  produced  by  muscular  contractions  is 
inversely  proportional  to  what  may  be  termed  the 
specific  energy  of  the  muscles  employed  in  the  effort. 

The  influence  of  psychic  factors  in  varying  the  re- 
sults of  muscular  tests  has  always  been  recognized 
(Kornfelds).  The  same  may  be  said  of  the  nerve 
factors.  All  these  facts  tend  of  course  to  render  un- 
certain the  results  obtained  by  the  exertion  tests  (pulse 


Tests  of  Heart  Function  173 

rate,  blood  pressure),  but  even  with  these  defects  this 
type  of  method  of  estimating  cardiac  function  is  of 
practical  value. 

The  chief  points  taken  into  consideration  in  this 
type  of  test  are  the  rate  of  the  pulse,  the  blood  pressure 
(systolic  and  diastolic)  and  the  area  of  cardiac  dull- 
ness or  size  of  the  heart  (percussion,  rontgenography). 

As  long  ago  as  1833  Donnell  showed  that  the  pulse 
rate  is  normally  slower  in  the  recumbent  than  in  the 
semi-erect  and  erect  positions.  Christ  in  1894  l  pro- 
posed to  register  the  exact  pulse  rate  after  exertion 
with  the  sphygmograph  provided  with  a  time  marker. 
He  likewise  invented  an  apparatus  by  which  the  patient 
could  undertake  a  measured  amount  of  exertion  on 
a  steppage  machine.  Rosenbach  in  the  same  year  em- 
phasized the  importance  of  noting  the  condition  of 
the  skin  after  the  performance  of  the  exertion.  It 
was  his  belief  that  the  skin  remains  dry  if  the  heart  is 
competent  but  becomes  quickly  moistened  with  perspir- 
ation if  there  is  cardiac  insufficiency.  He  explained  the 
increased  sudation  on  the  ground  that  the  excretory 
function  of  the  skin  is  called  from  the  list  of  reserve 
forces  to  compensate  as  far  as  possible  for  the  cardiac 
inadequacy.  This  is  probably  not  the  correct  interpre- 
tation of  the  phenomenon  since  sweating  itself  re- 
quires the  expenditure  of  force.  It  is  probably  due 
to  vasomotor  causes. 

1.    The  Staircase  Test.     Selig's  Test  2 

Technique. — Count  the  pulse  and  take  the  systolic 
pressure.  Have  the  patient  ascend  a  flight  of  twenty 
steps,  rapidly.  Count  the  pulse  and  take  the  systolic 
pressure  after  the  ascension. 

'Archiv.  f.  klin.  Med.,  1894,  LIU,  1902. 
2Prag.  med.  Wchnschr.,  1905,  XXX,  418,  432. 


174      Manual  of  Vital  Function  Testing  Methods 

Under  normal  circumstances,  there  is  an  increase 
in  the  pulse  rate  of  20  beats  per  minute  on  an  average 
and  a  rise  of  blood  pressure  of  8  millimeters  of  Hg. 

If  the  myocardium  is  insufficient  there  will  be  an 
increase  in  the  pulse  rate  of  30  beats  per  minute  or 
more.  The  blood  pressure  rise  will  be  slower  and 
average  about  6  mm.  of  Hg.  The  rise  may  be  fol- 
lowed rather  suddenly  by  a  fall  below  normal  or  the 
preliminary  rise  may  be  absent. 

The  length  of  time  required  for  recovery  to  the 
normal  systolic  pressure  may  be  taken  as  a  measure 
of  the  amount  of  cardiac  insufficiency  present. 

The  staircase  test  on  account  of  its  simplicity  is  often 
employed  by  clinicians. 

The  "hopping  test"  is  a  modification  of  the  Selig 
test,  which  has  been  used  for  years  as  a  routine  method 
of  eliciting  a  latent  cardiac  insufficiency.  The  patient 
is  instructed  to  hop  20  paces  on  one  foot  and  a  com- 
parison is  then  made  between  the  pulse  rate  before 
and  after  the  exertion. 

One  serious  objection  to  the  "hopping  test"  is  that 
the  actual  amount  of  work  performed  by  the  indi- 
vidual to  be  tested  cannot  be  computed.  In  the  method 
of  climbing  stairs,  the  amount  of  energy  expended  can 
be  approximately  known.  The  amount  of  work  done 
in  foot  pounds  will  be  equal  to  the  product  of  the 
weight  of  the  individual  in  pounds  into  the  number  of 
feet  ascended. 

The  advantage  of  this  simple  test  is  that  it  can  be 
performed  without  any  special  apparatus,  which  is  the 
chief  objection  from  a  practical  standpoint  to  some 
of  the  functional  cardiac  tests  which  have  been  sug- 
gested. 


Tests  of  Heart  Function  175 

2.    Graupner's  Test  3 

Graupner  found  at  Nauheim  in  observing  the  reac- 
tion of  patients  after  the  exercises  carried  out  as  a 
part  of  the  treatment  of  cardiopathies,  that  persons 
with  weakened  hearts  showed  a  different  type  of  reac- 
tion from  those  with  normal  or  nearly  normal  myo- 
cardia. 

Under  normal  circumstances,  as  is  well  known,  the 
pulse  rate  and  the  systolic  blood  pressure  rise  after 
exertion,  returning  to  normal  after  a  fairly  short  in- 
terval. If  the  exertion  is  sufficiently  prolonged  and 
arduous  they  may  fall  below  the  normal.  Graupner 
discovered  that  after  the  pulse  rate  has  risen  and  again 
fallen  to  normal  after  an  exertion,  the  systolic  pres- 
sure rises  gradually  to  a  maximum,  which  is  reached 
in  a  few  minutes,  usually  about  six,  declining  to  normal 
in  about  18  to  20  minutes.  The  rise  of  blood  pressure 
following  the  pulse  rise  is  called  the  normal  erholung. 
In  weakened  hearts,  even  if  the  weakness  is  slight, 
Graupner  found  that  the  erholung  occurs  but  it  is  less 
in  amount  than  normal  and  is  delayed  beyond  the 
normal  interval,  usually  to  about  12  minutes.  If  the 
heart  is  seriously  weakened  the  erholung  may  be  ab- 
sent altogether,  the  blood  pressure  declining  from  the 
start  then  gradually  rising  to  normal.  In  normal  cases 
the  pulse  reaches  its  normal  in  5  to  10  minutes. 

Technique  of  Graupner's  Test. — A  Zuntz  Ergom- 
eter  4  of  the  bicycle  or  weight  and  pulley  type  is  used 
in  conducting  the  test.  The  patient  turns  a  wheel 
which  is  supplied  with  a  brake  and  adjustments  for 
measuring  the  amount  of  work  expended.  Tests  are 

3Bcrl.    klin.   Wchnschr.,    1902,    174;    Deutsch.    med.    Wchnschr., 
1906,  XXXII,  1029. 
*  Centrbl.  f.  Physiol.,  1898,  502. 


176      Manual  of  Vital  Function  Testing  Methods 

made  on  successive  days  at  the  same  hour.  The  work  is 
therefore  done  by  the  same  muscle  groups.  It  is  im- 
portant not  to  carry  the  work  to  the  point  of  exhaus- 
tion or  strain.  Mental  excitement  must  be  absent. 
The  pulse  rate,  blood  pressure  and  size  of  the  heart 
are  noted  before  and  after  the  test. 

Arm  muscle  work  may  be  substituted  for  thigh  muscle 
work  on  the  same  machine  and  this  was  done  by  Graup- 
ner  in  his  later  researches. 

Cabot  5  and  Bruce  have  recommended  using  a  meas- 
ured amount  of  stair  climbing,  which  of  course  is  a 
more  practicable  and  generally  useful  method.  They 
estimate  the  amount  of  work  in  foot  pounds  which  is 
readily  computed  by  multiplying  the  number  of  pounds 
the  individual  weighs  by  the  number  of  feet  ascended. 

Graupner  came  to  the  following  conclusions  as  a 
result  of  his  rather  extensive  investigations :  If  the 
blood  pressure  remains  constant  after  the  exercise  the 
heart  muscle  is  sufficient.  If  the  blood  pressure  falls 
after  the  exercise  there  is  cardiac  insufficiency.  If  the 
blood  pressure  rises  but  returns  to  normal  there  is  com- 
pensatory sufficiency.  If  the  blood  pressure  rises  then 
rapidly  falls  without  a  tendency  to  subsequent  rise  the 
heart  muscle  is  fatigued. 

Graupner  stated  as  his  belief  that  if  the  pulse  is 
accelerated  and  the  patient  becomes  short  of  breath 
after  the  performance  of  work  equivalent  to  45  to  300 
kilograms  the  heart  is  manifestly  insufficient. 

Several  authors  have  corroborated  Graupner's  view 
that  a  persistent  tendency  toward  a  fall  of  blood  pres- 
sure after  the  exertion  denotes  cardiac  insufficiency. 
According  to  Graupner's  later  observation  persons 
with  normal  hearts  can  perform  arm  muscle  work  on 
the  ergometcr  equivalent  to  from  3,000  to  20,000  kilo- 
•  Amer.  Jour.  Med.  Sc.,  CXXXIV,  1907,  491. 


Tests  of  Heart  Function  177 

grams  per  hour.  If  the  figures  fall  below  1000  kilo- 
grams per  hour  there  is  cardiac  insufficiency.  If  meas- 
urements are  made  every  half  minute  after  exercise  it 
was  found  that  the  amount  of  variability  in  the  blood 
pressure  corresponds  with  the  insufficiency  of  the  heart, 
in  other  words,  that  the  greater  the  heart  weakness 
the  greater  are  the  variations  in  the  pressure  and  the 
longer  'the  time  required  for  the  status  quo  to  be 
restored.  This  does  not  wholly  occur  for  30  to  35 
minutes. 

Some  observers  have  found  that  a  lowering  of  the 
blood  pressure  after  exertion  may  be  found  in  trained 
athletes  and  according  to  the  terms  of  the  test  this 
should  denote  cardiac  insufficiency.  But  as  Hirsch- 
felder 6  states,  "the  heart  of  the  trained  athlete  is 
habitually  throwing  out  an  amount  of  blood  suited 
not  to  the  needs  of  the  moment  but  to  the  needs  of 
the  periods  of  exercise  to  which  he  has  accustomed 
himself.  The  systolic  output  is  above  normal  when 
the  exercise  (and  hence  the  increased  production  of 
C02)  is  slight.  The  heart  is  then  able  to  take  care  of 
the  excess  of  C02  production  in  exercise  without  in- 
creasing the  output  and  hence  the  vasodilatation  in 
the  muscles  is  the  only  factor  influencing  the  blood 
pressure.  When  the  exercise  becomes  severe  the  other 
mechanisms  begin  to  play  a  role. 

Also  in  certain  patients  with  diseased  hearts  the 
blood  pressure  has  been  found  to  rise,  it  is  claimed, 
because  of  high  pressure  stasis.  This  rise,  however, 
comes  later  than  in  normal  cases. 

Cabot  and  Bruce  as  a  result  of  their  trial  of  Graup- 
ner's  test  in  seventy-five  experiments  believe  that  it  is 
reliable.  They  say  "the  main  outlines  of  Graupner's 
contention  can  be  easily  verified  by  anyone.  Run 

6  Hirschfelder,  Diseases  of  the   Heart  and  Aorta,  p.  286. 


178      Manual  of  Vital  Function  Testing  Methods 

quickly  up  two  flights  of  stairs  and  then  stop  and 
count  your  pulse.  After  the  immediate  acceleration 
is  passed  or  during  the  slowing  of  the  pulse  following 
it  you  will  note  that  the  heart  beat  and  the  strength 
of  the  pulse  become  markedly  exaggerated.  One  feels 
the  thump  thump  of  the  heart  against  the  ribs  much 
more  strongly  after  the  pulse  has  almost  or  quite 
reached  its  normal  rate  than  during  the  period  when 
the  pulse  is  most  accelerated.  .  .  .  As  regards  the 
phenomenon  designated  by  Graupner  as  the  normal 
erholung  we  can  verify  his  findings  and  we  likewise 
agree  with  him  in  the  results  of  our  experiments  upon 
seriously  weakened  hearts.  In  some  of  the  cases  be- 
lieved by  us  from  ordinary  examination  of  the  heart 
to  be  normal  there  was  considerable  variation  from 
the  ordinary  curve  of  blood-pressure  after  exertion. 
Cases  of  valvular  disease  with  good  compensation 
showed,  as  might  have  been  expected,  a  normal  curve." 

Tests  like  that  of  Graupner  in  which  blood  pres- 
sure estimations  are  used  as  a  criterion  of  cardiac 
function  are  founded  upon  observations  of  Masing 7 
and  others  that  the  normal  blood  pressure  rises  during 
exercise  and  falls  immediately  afterward. 

When  a  normal  individual  exercises  with  chest 
weights,  for  example,  the  blood  pressure  may  rise  10 
to  30  mm.  of  Hg.  If  the  individual  is  arteriosclerotic 
the  rise  of  blood  pressure  may  go  to  40  to  60  mm.  of 
Hg.  and  outlast  the  exercise  a  variable  length  of  time. 

Bauer  in  employing  this  test  used  a  stationary  bicycle 
and  this  is  a  good  method  because  the  blood  pressure 
estimations  can  be  easily  taken  in  the  arm  during  the 
performance  of  the  exercise.  According  to  Bauer  the 
bicycle  test  gives  for  normal  individuals  a  rise  of  5  to  10 
mm.  of  Hg.,  while  in  those  with  cardiac  insufficiency 

'  Dcutsch.  Arch.  f.  klin.  Mcd.,  Lcipz.,  1901,  LXXI,  253. 


Tests  of  Heart  Function  179 

there  may  be  a  fall  of  equal  degree  (5  to  10  mm.  of 

Hg.)- 

The  great  difficulty  with  this  test  is  that  it  has  been 
found  that  in  trained  athletes  the  blood  pressure  may 
fall  instead  of  rising  at  the  commencement  of  mild  ex- 
ercise and  the  fall  may  last  for  a  considerable  period, 
thus  making  the  reaction  of  the  strong  man  some- 
what similar  to  that  of  the  weak.  The  proper  interpre- 
tation of  this  fact  has  be.en  given. 

As  Hirschfelder  states  all  functional  tests  of  cardiac 
efficiency  if  based  upon  mathematical  changes  in  pulse 
and  blood  pressure  may  lead  to  ambiguous  results. 
This  is  no  objection,  however,  to  the  application  of  the 
tests  but  only  to  their  too  strict  interpretation.  The 
appearance  of  the  patient  after  the  performance  of 
the  physical  tests  is  of  course  extremely  important. 
Accelerated  or  labored  breathing,  holding  the  breath, 
dilatation  of  the  nostrils,  drawing  in  of  the  corners  of 
the  mouth,  darkness  or  pallor  of  the  cheeks,  sweating, 
palpitation  and  so  forth,  all  these  are  signs  of  cardiac 
insufficiency  more  important  perhaps  than  the  mathe- 
matical results  of  individual  tests. 

According  to  Hirschfelder  the  most  reliable  nu- 
merical criterion  of  cardiac  efficiency  is  whether  a  given 
strain  causes  the  heart  to  diminish  in  size  (increase 
in  tonicity)  or  to  dilate  (decrease  in  tonicity — over- 
strain).8 

3.     Mendelsohns  Test  Q 

Teclinic. — -The  pulse  is  carefully  counted  in  the 
standing,  sitting  and  recumbent  postures  and  the  fig- 
ures noted.  This  may  be  repeated  several  times  and 

8  Hirschfelder,  loc.  cit.,  199. 

8  XIX  Kongr.  f.  Inn.  Med.,  1901. 


180      Manual  of  Vital  Function  Testing  Methods 

an  average  taken.  The  person  to  be  tested  then  per- 
forms muscular  work  upon  a  Gaertner  ergostat  by 
means  of  which  the  amount  of  work  may  be  measured.10 
The  Gaertner  ergostat  is  an  instrument  not  easily  se- 
cured and  for  this  reason  the  original  test  is  not  much 
employed.  By  the  simple  method,  however,  of  Cabot 
and  Bruce  above  mentioned  of  having  the  patient  per- 
form a  given  amount  of  work  in  stair  climbing  which 
can  be  easily  calculated,  the  reaction  of  the  pulse  rate 
and  the  return  of  the  latter  to  normal,  which  is  the 
basis  of  the  Mendelsohn  tests,  can  be  readily  estimated. 
After  the  performance  of  varying  amounts  of  work  the 
patient  assumes  the  recumbent  posture  immediately 
and  the  time  is  noted  which  is  required  for  the  pulse  to 
return  to  the  normal  figure  previously  ascertained  for 
that  posture. 

The  first  criterion  of  the  Mendelsohn  test  is  based 
on  the  principle  that  when  the  heart  is  healthy  or  well 
compensated,  a  transition  from  vertical  to  horizontal 
position  is  accompanied  by  a  slowing  of  the  pulse  of 
10  or  12  beats  per  minute.  If  the  heart  is  insufficient 
or  decompensatcd  an  opposite  condition  may  prevail, 
namely,  the  pulse  becomes  quicker  in  the  recumbent 
posture  or  tends  to  remain  constant. 

Mendelsohn  contended  that  if  there  is  not  a  well 
marked  difference  in  the  pulse  rate  between  the  erect 
and  recumbent  postures  the  heart  is  incompetent. 

The  second  criterion  suggested  by  Mendelsohn  de- 
pends upon  the  principle  that  the  competent  heart 
is  able  to  return  immediately  to  a  normal  when  rest- 
ing after  a  strain.  He  suggested,  therefore,  that  an 
estimate  of  the  functional  capacity  of  the  heart  can 
be  obtained  by  noting  the  degree  of  facility  displayed 
by  the  organ  to  return  to  normal  conditions  after  meas- 
10  Allg.  AVien.  Med.  Zeit.,  188T,  Nos.  49  and  50. 


Tests  of  Heart  Function  181 

ured  exertion  in  which  extra  cardiac  energy  is  called 
into  play.  Mendelsohn  found  that  a  normal  heart 
after  performing  work  equivalent  to  100-200  kilograms 
returns  immediately  to  the  normal  with  rest  in  recum- 
bent posture.  After  500  kilograms  of  work  the  normal 
heart  is  accelerated  somewhat  for  a  varying  period  of 
time.  If,  however,  there  is  cardiac  insufficiency  very 
much  smaller  amounts  of  muscular  exertion  prove  exces- 
sive and  disturb  the  pulse  rate.  A  disturbance  of  rate 
with  failure  to  return  immediately  to  normal  following 
the  expenditure  of  25-50  kilograms  of  work  denotes 
cardiac  insufficiency. 

A  Variant  of  Mendelsohn's  Test. — When  a  normal 
individual  rises  from  the  reclining  to  the  standing  posi- 
tion the  heart  rate  is  accelerated,  but  it  is  usually 
stated  that  the  increase  ought  never  to  be  more  than 
20.  Beyond  20  one  has  the  right  to  assume  that  the 
myocardium  is  insufficient. 

This  test  from  its  extreme  simplicity  has  been  much 
used  and  is  capable  of  giving  some  valuable  informa- 
tion. But  nevertheless,  under  some  circumstances  it 
fails  to  do  so ;  for  example,  under  conditions  where 
the  psychic  role  may  play  a  part.  Here  the  increase 
of  pulse  rate  in  a  normal  individual,  that  is  normal  so 
far  as  the  myocardium  is  concerned,  may  be  inordinate 
and  out  of  proportion.  Hirschf elder  X1  says  that  per- 
sons with  enteroptosis  may  give  a  false  increase. 

4-     The  Katzenstein  Method  12 

Katzenstein  found  from  animal  experiments  that 
ligature  of  peripheral  arteries  produces  an  increase  in 

11  International  Clinics,  Vol.  IV,  1910,  p.  39. 
12Dcutsch.  med.  Wchnschr.,  1904,  Xo.  30,  p.  807;  also,  ibid.,  1907, 
XLIV,  No.   16. 


182      Manual  of  Vital  Function  Testing  Methods 

the  general  blood  pressure  without  change  in  the  pulse 
rate.  In  animals  with  weakened  hearts  he  demonstrated 
that  ligature  of  peripheral  arteries  produced  other  re- 
sults, namely  increased  pulse  frequency  and  irregulari- 
ties in  the  blood  pressure.  He  therefore  proposed  ap- 
plying the  principle  involved  to  clinical  medicine  as  an 
aid  to  determining  the  functional  capacity  of  the  heart 
muscle. 

His  method  consists  essentially  in  making  compres- 
sion upon  peripheral  arteries  (the  femorals)  so  as  to 
shut  off  the  circulation  in  the  lower  limbs,  and  observ- 
ing the  effects  upon  the  pulse  and  blood  pressure.  The 
author  of  the  test  found  in  cases  of  cardiac  insufficiency 
a  lowering  of  the  blood  pressure  and  a  simultaneous 
increase  in  the  pulse  rate,  both  of  which  deviations 
from  the  normal  appeared  to  maintain  a  proportionate 
relation  to  the  incompetency  of  the  heart  muscle. 

It  has  been  proposed  to  substitute  an  Esmarch  band- 
age for  digital  compression  of  the  arteries,  thereby 
doing  away  with  the  necessity  of  an  assistant. 

Technic  of  Kcitzenstein  Test. — Sometimes  called  also 
the  Marey-Katzenstein-Shapiro  Test. 

The  patient  is  put  in  a  reclining  posture  and  the 
pulse  rate  and  blood  pressure  taken.  Pressure  is  then 
made  for  two  and  one-half  to  five  minutes  over  both 
femoral  arteries  in  the  groins  by  means  of  the  fingers 
of  an  assistant  or  by  clastic  Esmarch  bandage,  or 
according  to  Morelli  by  inflatable  rubber  stockings. 
The  pulse  rate  and  blood  pressure  are  again  recorded. 

In  normal  individuals  with  sufficiency  of  the  myocar- 
dium the  pulse  diminishes  in  number.  The  blood  pres- 
sure rises  5  to  15  mm.  of  Hg.  With  sufficient  but 
hypertrophic  hearts  the  pulse  diminishes  or  remains 
the  same.  An  increase  of  15  to  40  mm.  of  Hg.  takes 
place  in  the  blood  pressure. 


Tests  of  Heart  Function  183 

In  cases  of  moderate  latent  cardiac  insufficiency  the 
blood  pressure  remains  unchanged.  The  pulse  rate 
is  unchanged  or  increased.  In  higher  grades  of  cardiac 
insufficiency  the  blood  pressure  sinks  and  the  pulse 
rate  increases. 

For  practical  purposes  it  may  be  said  that  with 
sufficiency  of  the  heart  muscle  the  pulse  remains  un- 
changed or  diminishes  in  number  and  the  blood  pres- 
sure rises.  If  the  pulse  increases  and  the  blood  pres- 
sure remains  the  same  or  falls  after  the  Katzenstein 
test  the  heart  is  insufficient. 

Norris  13  made  an  investigation  in  1907  with  a  view 
of  determining  the  adaptability  of  Katzenstein's  test 
to  clinical  use.  He  found  that  generally  speaking  the 
results  were  accurate  and  confirmatory  of  its  author's 
findings  but  many  exceptions  were  noted.  Some  of  the 
cases,  many  in  fact,  of  cardiac  weakness  which  re- 
sponded positively  to  the  test  did  so  in  an  extremely 
equivocal  manner,  leaving  practically  the  final  deter- 
mination a  matter  of  personal  equation  on  the  part  of 
the  investigator. 

As  a  corroborative  test  the  method  of  Katzenstein 
appears  to  possess  some  value,  but  as  an  independent 
test  of  cardiac  sufficiency  or  insufficiency  no  great  de- 
pendence can  be  placed  upon  it.  The  method  should 
be  used  with  caution  in  cases  of  severe  cardiac  weak- 
ness where  it  may  prove  to  be  actually  dangerous. 

5.     Herz's    Self -Che  eking    Test.14      Selbst-Hemmungs 

Probe 

Teclinic, — The  patient  is  placed  in  a  sitting  posture 
and  remains  so  until  the  pulse  rate  has  become  con- 

13  Blood  Pressure  and  Clinical  Applications,  Phila.,  1914,  p.  145; 
International  Clinics,  1907,  I,  17s,  p.  66. 

14  Deutsch.  med.  Wchnschr.,  1905,  31,  XXXI,  215. 


184      Manual  of  Vital  Function  Testing  Methods 

stant.  He  is  then  directed  to  contract  all  the  muscles 
of  hand  and  forearm  with  all  his  force  and  to  flex  and 
extend  the  forearm  with  all  possible  force,  performing 
the  motions  slowly,  paying  strict  attention  to  the  per- 
formance and  endeavoring  to  antagonize  his  movements 
as  forcefully  as  possible. 

In  healthy  persons  the  pulse  rate  is  unaffected  by 
this  maneuver,  whereas  in  persons  with  a  weak  heart 
the  rate  increases  5  to  20  beats  per  minute. 

This  test  has  been  found  to  possess  a  certain  degree 
of  reliability  but  it  does  not  possess  so  absolute  a  value 
as  was  originally  ascribed  to  it  by  its  author.  Some- 
times healthy  persons  give  a  positive  reaction.  Hirsch- 
felder  believes  that  the  vagus  plays  a  part  in  it  and 
that  the  results  are  not  altogether  indicative  of  cardiac 
output  and  vigor. 


6.     Gymnastic  Resistance  Test.    Herz-Harancliipy 
Test 


This  consists  in  having  the  patient  execute  three 
types  of  resisted  movements.  First  a  movement  of 
flexion-extension  of  the  forearm,  the  patient  being 
seated.  Second,  a  movement  of  separation-approxi- 
mation of  the  thighs  in  sitting  posture.  Third,  a  move- 
ment of  abduction-adduction  of  the  extended  lower 
limbs,  the  patient  seated.  All  of  these  motions  are  re- 
sisted equally.  A  slight  rest  is  given  between  each 
series.  The  whole  test  lasts  25  to  30  seconds.  Prior 
to  the  movements  the  systolic  blood  pressure  is  taken. 
While  the  movements  arc  being  executed  and  during 
repose  the  blood  pressure  is  retaken.  In  a  normal  in- 
dividual there  should  be  a  variation  in  the  blood  pres- 


Tests  of  Heart  Function  185 

sure  as  a  result  of  the  exercises  of  not  more  than  10 
to  15  mm.  of  Hg.  In  cases  of  cardiac  insufficiency  it 
reaches  20  to  30  mm.  of  Hg. 

7.     The  Russian  Test.15     "Holding  the  Breath"  Test 

This  simple  test  for  estimating  the  integrity  of  the 
cardiac  muscle  has  been  in  long  use  empirically.  We 
have  called  it  the  Russian  test  because  Herz  has  men- 
tioned the  fact  that  he  could  not  find  any  specific  men- 
tion of  it  in  the  literature  but  knew  that  it  was  com- 
monly employed  by  certain  Russian  physicians. 

The  test  is  well  called  "Holding  the  Breath"  test 
since  it  consists  simply  in  directing  the  patient  to  stop 
breathing  for  as  long  a  time  as  possible.  This  ma- 
neuver puts  a  considerably  added  strain  upon  the 
myocardium,  particularly  the  right  ventricle.  Great 
variations  of  the  length  of  time  in  which  the  breath 
can  be  held  by  different  persons  are  found,  but  any 
marked  limitation  of  the  time  during  which  a  person 
can  inhibit  the  act  of  respiration  indicates  cardiac 
insufficiency.  If  the  period  of  voluntary  apnoea  is 
less  than  15  seconds  the  myocardium  may  be  considered 
insufficient. 

8.     The  Venous  Pressure  Test.    Schott's  16  Test 

The  principle  of  the  Schott  test  depends  upon  the 
fact  that  in  health  if  the  arm  is  elevated  to  an  angle 
of  60  degrees  with  the  patient  in  a  recumbent  posture 
and  making  no  other  exertion  the  venous  pressure  in- 
creases only  .5  cm.  of  H2O  or  sometimes  may  remain 

35  Die  Herz  Krankheiten,  \Vien,  1912,  p.   12,5. 
16Deutsch.  Arch.  f.  klin.  Med.,  1912,  CVIII,  537. 


186      Manual  of  Vital  Function  Testing  Methods 

stationary  or  even  fall.  If,  however,  the  cardiac  muscle 
is  insufficient,  a  rise  in  the  venous  pressure  takes  place 
which  may  even  be  considerable  (4  to  7  cm.).  Accord- 
ing to  Schott,  any  reading  above  3  cm.  denotes  cardiac 
insufficiency. 

Several  methods  have  been  devised  to  determine  ven- 
ous blood  pressure.  Von  Frey  and  Gaertner  considered 
that  the  venous  pressure  can  be  determined  by  con- 
sidering it  equal  to  the  height  above  the  angle  of 
Ludwig  at  which  the  veins  of  the  hand  are  seen  to 
collapse  when  the  arm  is  raised.  Von  Recklinghausen 
used  an  apparatus  whereby  the  vein  could  be  compressed 
by  inflating  a  small  rubber  capsule  provided  with  a 
glass  window  in  the  top  of  a  rubber  dam  floor  with  an 
opening  in  its  center.  The  dam  is  coated  with  glycerine 
to  insure  perfect  apposition  to  the  skin.  It  is  placed 
over  a  vein  on  the  back  of  the  hand  or  wrist  and  the 
system  inflated  until  the  vein  is  seen  to  disappear,  at 
which  point  the  pressure  is  read  off  on  a  water  ma- 
nometer. Eyster  and  Hooker  modified  the  method  by 
using  an  aluminum  chamber  with  a  glass  top,  the  two 
ends  concave  to  avoid  pressure  on  the  vein.  The 
normal  venous  pressure  obtained  by  this  instrument  at 
the  sterno-xyphoid  articulation  is  5  to  10  cm.  of  H2O. 
In  cardiac  cases  it  may  rise  to  27  cm.  or  more.  The 
pressure  in  the  lip  capillaries  may  be  estimated  by  using 
the  point  of  blanching  as  the  criterion.  The  study  of 
venous  pressure  is  of  some  importance  as  an  index  of 
accumulation  of  blood  in  the  veins  and  may  therefore 
become  to  some  extent  an  index  of  heart  failure. 


Tests  of  Heart  Function  187 


II.        APPLICATION    OF    CARDIAC     REFLEX    ESTIMATIONS    IN 
DETERMINING    HEART    FUNCTION 

MerTden's  Test 

The  best  known  cardiac  reflexes  are  those  of  Abrams 
and  Livierato. 

Abrams'  reflex  consists  of  a  diminution  of  the  area 
of  precordial  dullness  following  energetic  friction  over 
the  heart.  Livierato's  reflex  consists  of  an  increase  of 
the  area  of  cardiac  dullness  following  percussion  over 
the  epigastric  region.  In  Abrams'  reflex  the  left  ven- 
tricle is  chiefly  affected  and  in  Livierato's  reflex  the 
right  ventricle.  The  heart  is  so  much  less  meiopragic 
(weakened)  in  proportion  to  its  capacity  to  give  a 
positive  Abrams  and  a  negative  Livierato. 

Technique  of  Reflex  Test. — Map  out  the  area  of 
precordial  dullness  carefully  by  light  percussion  and 
mark  with  dermographic  pencil.  Make  precordial  fric- 
tion for  one  minute,  using  rough  cloth  or  a  rubber 
eraser.  Follow  this  by  rapid  percussion  of  the  pre- 
cordial area.  After  three  to  five  minutes  wait,  map  out 
the  area  of  dullness  by  light  percussion.  If  the  reflex 
is  normal,  the  area  will  be  smaller  than  before. 

In  using  Livierato's  reflex  the  technique  is  the  same 
to  determine  the  area  of  cardiac  dullness.  The  reflex 
is  elicited  by  making  a  series  of  rapid  rather  forceful 
strokes  for  one  minute  over  the  median  line  of  the  ab- 
domen. After  three  minutes'  interim,  the  area  of  dull- 
ness is  again  made  out  and  if  the  reflex  is  positive  the 
right  border  of  cardiac  dullness  will  be  found  increased. 
The  two  reflexes  should  not  be  applied  to  the  same  pa- 
tient on  the  same  day. 


188      Manual  of  Vital  Function  Testing  Methods 

III.       ESTIMATION    OF    SODIUM    CHLORIDE    ELIMINATION    AS 
A   TEST   OF   CARDIAC    SUFFICIENCY 

Vaquez-Digne  Test 

This  test  is  based  upon  the  supposition  that  the 
elimination  of  sodium  chloride  is  affected  by  the  suf- 
ficiency or  insufficiency  of  the  heart  muscle.  In  indi- 
viduals in  whom  the  integrity  of  the  heart  muscle  is 
normal  any  excess  of  salt  ingested  should  be  promptly 
eliminated  from  the  circulation  and  passed  out  thro 
the  kidney.  In  cases  of  cardiac  insufficiency  even  when 
latent,  it  is  contended  that  the  salt  elimination  is  defec- 
tive. 

In  applying  this  test  the  individual  is  put  for  some 
days  on  a  fixed  sodium  chloride  ration  and  when  an 
equilibrium  is  established  the  amount  of  salt  injected 
is  doubled  and  a  quantitative  estimation  of  sodium 
chloride  in  the  urine  made.  In  cases  of  cardiac  in- 
sufficiency there  will  be  defective  elimination  and  if 
the  diminution  of  function  is  considerable  there  may 
be  oedema  and  signs  of  partial  decompensation  set  up. 
The  integrity  of  the  kidney  function  must  be  previously 
determined. 


IV.        MODERN     CLINICAL  AND     INSTRUMENTAL     METHODS 

OF        INVESTIGATING  CARDIOVASCULAR         CONDITIONS: 

THEIR   APPLICABILITY  TO    ESTIMATING    CARDIAC    FUNC- 
TION 

1.     Spliygmomanometer  as  an  Index  of  Cardiac  Func- 
tion.     Work-Velocity  Ratio 

The  sphygmomanometer  is  the  instrument  in  vogue 
of  our  day.     The  chief  value  of  this  instrument  is  to 


Tests  of  Heart  Function  189 

register  the  height  of  the  blood  pressure  and  since  its 
introduction  it  has  no  doubt  contributed  to  a  clearer 
differentiation  of  states  of  hyper-  and  hypotension. 
Like  the  sphygmograph,  it  is  teaching  physicians  to 
become  more  expert  in  the  use  of  their  sense  of  touch 
and  just  .  as  the  latter  instrument  (sphygmograph) 
taught  physicians  to  differentiate  the  arhythmias  with- 
out the  use  of  the  instrument  in  many  cases,  so,  too, 
it  may  come  to  pass  that  careful  comparison  of  pal- 
patory  pulse  estimations  of  pressure  with  instrumental 
readings  of  pressure  carried  out  day  by  day  in  cases 
of  hyper-  and  hypotension  will  finally  educate  the 
physician  to  make  correct  deductions  in  many  cases 
without  the  use  of  the  instrument.  There  will  always 
remain  a  certain  proportion  of  cases,  however,  in 
which,  owing  to  various  physical  factors,  an  accur- 
ate digital  estimation  of  the  systolic  blood  pressure 
is  impossible.  A  distinguished  clinician  who  has  cul- 
tivated this  perception  to  a  remarkable  degree  is 
quoted  as  saying:  "I  can  estimate  the  blood  pressure 
with  the  fingers  alone  quite  accurately  in  about  eight 
cases  out  of  ten,  but  those  in  which  it  is  of  real  im- 
portance are  always  the  other  two." 

Modern  sphygmomanometry  will,  however,  do  some- 
thing more  than  show  the  variations  in  the  systolic 
blood  pressure.  Recently,  since  the  introduction  of 
the  auscultatory  or  auditory  method  of  using  the 
sphygmomanometer,  the  method  of  Korotkof,  a  more 
accurate  means  of  finding  the  exact  diastolic  pressure 
has  been  found  than  could  be  had  by  means  of  the  older 
visual  method  with  the  vertical  mercury  or  other 
manometers. 

With  accurate  data  concerning  the  systolic  and 
diastolic  blood  pressure,  we  are  in  a  better  position  to 
interpret  results  in  terms  of  cardiovascular  function 


190      Manual  of  Vital  Function  Testing  Methods 

than  we  are  by  means  of  the  systolic  pressure  alone. 

In  order  to  fully  appreciate  just  what  may  be  ex- 
pected from  such  data  as  the  above  in  the  interpretation 
of  cardiac  function,  we  must  bear  in  mind  of  course 
a  few  simple  physiological  facts. 

The  blood  pressure,  that  is,  the  systolic  blood  pres- 
sure, depends  mainly  upon  the  contractile  powers  of 
the  heart  muscle  which  enables  it  to  pump  the  blood 
into  the  arteries,  against  the  peripheral  resistance 
caused  by  the  friction  of  the  blood  on  the  vessel  walls. 
The  peripheral  resistance  depends  upon  the  tonicity 
and  physical  state  of  the  vessel  walls.  Under  normal 
circumstances  the  elasticity  of  the  coats  of  the  arteries 
provides  for  a  continuous  instead  of  an  intermittent 
flow  of  blood  which  would  be  the  case  if  the  arteries 
were  rigid  tubes. 

The  systolic  or  maximum  pressure  will  approximately 
show  the  actual  pressure  or  work  developed  by  the  heart 
at  the  moment  of  systole.  The  diastolic  or  minimum 
pressure  will  show  the  degree  of  the  peripheral  re- 
sistance which  the  heart  has  been  able  to  overcome 
and  which  is  maintained  in  the  peripheral  circulation 
during  the  time  of  heart  refilling.  The  difference  be- 
tween the  highest  and  the  lowest  pressures  in  the  larger 
arteries,  that  is  the  difference  between  systolic  and 
diastolic  pressures,  is  known  as  the  pulse  pressure.  The 
pulse  pressure,  therefore,  is  the  measure  of  the  amount 
of  force  exerted  by  the  heart  in  maintaining  the  blood 
pressure  over  and  above  the  arterial  or  peripheral  re- 
sistance. To  this  extent  then  the  pulse  pressure  is  a 
measure  of  the  pumping  capacity  of  the  heart  and 
hence  is  of  some  importance  in  estimating  the  state  of 
cardiac  function. 

Gibson  has  called  attention  to  the  fact  that  there 
are  certain  normal  arithmetical  relations  which  are 


Tests  of  Heart  Function  191 

discoverable  in  a  study  of  the  three  factors — systolic 
pressure,  diastolic  pressure  and  pulse  pressure.  The 
relation  of  the  diastolic  pressure  to  the  systolic  pres- 
sure is  normally  as  two  is  to  three.  The  relation  of  the 
pulse  pressure  to  the  systolic  pressure  is  as  one  is 
to  three.  If  the  systolic  pressure  is  150  the  normal 
diastolic  pressure  will  be  approximately  100.  With 
a  systolic  pressure  of  150,  the  normal  pulse  pressure 
will  be  50.  Of  course  these  figures  represent  approxi- 
mate and  not  absolute  relations.  They  are  of  some 
service  in  estimating  cardiac  function  because  patho- 
logical relations  become  evident  and  the  presence  and 
also  to  a  certain  extent,  the  degree,  of  cardiac  overload 
may  be  appreciated. 

The  normal  arteries  will  apparently  withstand  a  con- 
tinual variation  in  pressure,  that  is  a  pulse  pressure  of 
35  to  50  mm.  of  mercury  without  deterioration.  Any 
great  increase  of  the  pulse  pressure  over  these  figures 
is  pathological  and  at  least  indicates  cardiac  overload 
and  consequently  justifies  suspicion  that  perhaps  the 
myocardium  may  not  long  succeed  in  maintaining  it. 
The  heart  manages  to  do  so  by  undergoing  hypertrophy 
and  when  this  has  been  accomplished  the  organ  may  be 
regarded  as  at  least  a  locus  mlnoris  reslstentice. 

A  quantitative  idea  of  the  undue  stress  may  be  ob- 
tained by  taking  the  difference  between  the  normal 
and  pathological  pulse  pressure.  When  this  is  multi- 
plied by  the  pulse  rate  and  this  by  60  (hour)  and  again 
by  24  (day)  a  concrete  idea  may  be  gained  of  the 
enormous  excess  of  energy  required  to  be  expended  by 
the  heart  in  a  day  to  overcome  pathological  peripheral 
resistance. 

Such  a  case,  however,  may  go  on  and  on  and  we  have 
no  exact  method  of  predicting  just  when  the  break  will 
come,  with  its  attendant  consequences  of  cardiac  in- 


192      Manual  of  Vital  Function  Testing  Methods 

sufficiency.  As  it  approaches,  however,  the  diastolic 
pressure  will  fall,  indicating  the  approaching  collapse 
of  the  cardiovascular  mechanism.  The  larger  the 
pulse  pressure  in  relation  to  the  diastolic  pressure,  the 
greater  the  strain  on  the  heart  will  be  and  the  more 
imminent,  therefore,  is  decompensation.  A  high  systolic 
pressure  with  a  relatively  low  diastolic  pressure  indi- 
cates, therefore,  impending  collapse  of  the  heart  muscle. 
If  after  treatment  the  diastolic  pressure  rises  and  the 
pulse  pressure  falls  the  indication  is  that  recompensa- 
tion  is  taking  place. 

Technique  of  Sphygmomanometry. — A  brief  account 
only  of  the  method  of  obtaining  the  systolic  and  dias- 
tolic blood  pressure  will  be  given.  A  more  complete 
description  is  properly  found  in  texts  devoted  to  the 
subject  of  blood  pressure.  The  arm  band  is  applied 
to  the  bared  arm  above  the  elbow  by  placing  the  broad 
end  containing  the  rubber  bag  over  the  region  of  the 
brachial  artery.  Wrap  the  band  bandagewise  around 
the  arm  and  tuck  in  the  narrow  end.  Connect  up  the 
indicator  and  pump.  Apply  the  sphygmometroscope 
or  ausculoscope  or  stethoscope  over  the  brachial  artery 
at  the  bend  of  the  elbow.  Increase  the  pressure  until 
all  sounds  are  gone,  then  gradually  admit  air.  The 
sounds  which  are  heard  are  divided  into  four  phases. 
First,  a  loud  clear-cut  snapping  tone.  This  is  caused 
by  the  first  and  the  early  pulse  waves  that  break 
through  the  constriction  and  its  beginning  repre- 
sents the  systolic  pressure.  Owing  to  the  greater 
sensitiveness  of  the  ear  than  the  fingertip  it  is  usually 
heard  some  5  to  10  mm.  above  the  point  where  the 
radial  pulse  is  first  felt.  In  normal  cases,  it  is  said 
to  last  during  the  fall  of  about  14  mm.  of  pressure. 
Second,  a  murmur  or  succession  of  murmurs  lasting 
during  the  fall  of  about  20  mm.  This  phase  is  not 


Tests  of  Heart  Function  193 

always  present  and  if  absent  the  first  and  third  phases 
merge  into  one  another.  Third,  a  clear  tone  resembling 
the  first,  sometimes  less  well  marked  but  often  louder. 
This  lasts  during  a  fall  of  about  5  mm.  Fourth,  a 
rather  sharp  transition  from  the  loud  to  the  dull  tone 
recently  proved  to  be  the  time  of  diastolic  pressure. 

As  there  had  been  considerable  discussion  as  to 
whether  the  diastolic  pressure  corresponded  to  the  be- 
ginning or  ending  of  the  fourth  phase,  Warfield  under- 
took its  investigation  some  years  ago  through  a  series 
of  animal  investigations  and  comparison  of  cases  with 
accurate  graphic  records.  These  have  been  confirmed 
by  others  and  the  point  now  seems  to  be  settled,  that 
diastolic  pressure  coincides  with  the  beginning  of  the 
fourth  phase. 

Functional    Tests    Based    on   Direct    Blood   Pressure 
Determinations. 

I.  The  Cardiac  Efficiency  Factor  of  Tiegerstedt. — 
The  pulse  pressure  shows  approximately  the  systolic 
output  in  energy  and  the  velocity  of  the  blood  stream 
will  be  the  product  of  this  energy  into  the  number  of 
cardiac  cycles  (pulse  beats)  per  minute.  In  other 
words,  pulse  pressure  (PP)  times  pulse  rate  (PR) 
will  equal  velocity  of  flow. 

Since  the  interventricular  pressure  is  almost  con- 
stant throughout  systole,  it  is  evident  that  the  work 
done  by  the  heart  is  tolerably  constant  throughout  the 
period.  The  work  done  by  the  heart  in  a  unit  of  time 
will  be  the  product  of  its  maximum  energy,  systolic 
pressure  (SP),  multiplied  by  the  pulse  rate  (PR),  mul- 
tiplied by  the  duration  of  systole.  Since  the  inter- 
ventricular  pressure  is  constant,  the  factor  duration  of 
systole  may  be  eliminated  and  work  done  equals  product 


194      Manual  of  Vital  Function  Testing  Methods 

of  SP  X  PR  (systolic  pressure  times  pulse  rate). 
The  reason  why  interventricular  pressure  is  constant 
is  because  of  the  fact  that  the  heart  liberates  all  avail- 
able energy  at  each  contraction.  A  concrete  example 
will  readily  show  how  the  velocity  work  ratio  is  ob- 
tained. If  the  SP  =  =  130,  DP  ==  85,  then  PP  ==  45. 
If  PR  =  70  then  PP  45  X  PR  70  =  3,100  (velocity), 
and  SP  130  X  PR  70  ==  9,100  (work),  the  ratio  then 
becomes 

PP 

^jjj  =  Blood  pressure  coefficient  (Tiegerstedt). 

fe-i 

PP  X  PR  _  Velocity 
SP  X  PR  ~      Work 

This  is  the  velocity  work  ratio  or  coefficient  of  heart 
pumping  efficiency.  The  velocity  work  relation  in  this 
example  is  one  to  three  and  this  is  about  the  normal 
ratio.  Expressed  in  percentages,  it  varies  normally 
from  25  to  35  f/c .  Increase  in  this  ratio  may  indicate 
cardiac  insufficiency. 

II.  The  Cardiac  Strength,  Cardiac  Weakness  Ratio 
of  Goodman  and  Howell. — These  authors  have  studied 
the  duration  of  the  four-tone  phases  of  auscultatory 
blood  pressure  estimation  in  a  series  of  normal  and 
pathological  cases.  Their  test  is  based  on  the  ratio 
of  these  phases  to  the  pulse  pressure  and  to  one  an- 
other. They  set  forth  their  views  as  follows : 

1.  "The  first  phase  or  tone  phase  serves  principally 
as  an  index  as  to  how  far  the  pressure  must  fall  before 
the  blood  current  can  be  sustained  past  the  obstruction 
in  the  vessel  caused  by  the  cuff  at  a  sufficient  velocity 
and  for  a  sufficient  duration  to  produce  the  murmur. 
Hence  the  information  it  affords  is  of  negative  rather 
than  of  positive  value.  In  other  words,  its  normal 


Tests  of  Heart  Function  195 

duration  is  of  no  value  but  an  increase  or  decrease  in 
length   is   of  importance. 

2.  The  second  or  the  murmur  phase  seems  to  be  espe- 
cially dependent  upon  cardiac   effectiveness,   for  it  is 
in  this  phase  alone  that  the  individual  sounds  possess 
a    distinct   element    of   duration    and    this    protracted 
energy,  for  so  it  must  be  regarded,  must  evidently  come 
from  the  heart. 

3.  The  third  phase  or  second  tone  phase  depends 
not  alone  on  cardiac  efficiency  but  also  on  the  character 
of  the  vessel  wall.    The  more  sclerotic  the  vessel  and  the 
greater  the  cardiac  hypertrophy,  the  more  favorable 
are  the  conditions  for  the  production  of  a  clear  tone. 

4.  As  the  fourth  phase  or  dull  tone  may  be  pro- 
duced by  a  resilient  vessel,   receiving  a  normal  pulse 
shock,  or  by  a  rigid  vessel  receiving  a  weakened  shock, 
its  interpretation  is  more  difficult.     If  our  assumptions 
are  correct  it  is  evident  that  increases  in  the  second 
and  third  phases   are  dependent   on   cardiac   strength 
and  circulatory  deficiency,  while  the  first  and  fourth 
phases  suffer  increase  when  there  is  cardiac  weakness. 
Furthermore,  in  dealing  with  increases  or  decreases  in 
any  particular  phase  it  is  important  to  know  at  the 
expense  of  what  adjacent  phase  this  has  occurred.    It  is 
apparent  that  an  increase  in  the  third  phase  for  example 
at  the  expense  of  the  second  has  not  the  same  signifi- 
cance as  an  increase  of  this  phase  at  the  expense  of 
the  fourth.      In  the  first  instance  the  unit  of  cardiac 
strength  which  we  obtain  by  adding  the  lengths  of  the 
second  and  third  phases  has  not  been  materially  changed 
while  in  the  latter  it  has  been  increased.     For  this  rea- 
son  we    recommend   that   the   sum   of   the   second    and 
third  phases  be  compared  with  the  sum  of  the  first  and 
fourth  phases  in  order  to  determine  whether  the  ele- 
ments of  force  or  those  of  weakness  are  predominating. 


196      Manual  of  Vital  Function  Testing  Methods 

Aside  from  the  value  of  the  persistence  of  the  fourth 
phase  in  aortic  insufficiency  little  of  diagnostic  value  has 
developed  in  regard  to  the  length  of  any  individual 
phase.  Advantage  has  been  derived,  however,  from 
studying  the  changes  in  the  sequence  reading,  specially 
in  decompensating  cardiac  lesions  as  the  patient  im- 
proves or  not.  In  these  cases  changes  in  the  percent- 
ages of  the  various  phases  are  not  the  only  significant 
feature  but  internal  peculiarities  appear.  Or  to  put 
it  another  way,  sequence  readings  have  a  functional 
rather  than  an  organic  significance.  Our  results  uni- 
formly show  that  with  decompensation  or  circulatory 
disturbances  of  lesser  degree,  the  element  of  heart  weak- 
ness (the  sum  of  the  first  and  fourth  phases)  progres- 
sively encroaches  upon  that  of  heart  strength  (the  sum 
of  the  second  and  third  phases).  The  second  phase 
appears  to  be  the  one  which  is  with  most  difficulty 
sustained.  The  fourth  phase  as  weakness  gains  the 
ascendency,  is  usually  the  first  to  lengthen  the  element 
of  cardiac  weakness  by  its  encroachment  on  the  third 
phase,  but  encroachment  of  the  first  phase  on  the  sec- 
ond soon  adds  its  share  to  the  total."  17 

The  average  duration  in  mm.,  the  fall  of  and  per- 
centages of  the  pulse  pressure  of  the  different  phases 
in  normal  individuals  are: 

mm.  per  cent. 
First  phase              14  31.1 

Second  phase  20  44.4 

Third  phase  5  11.1 

Fourth  phase  6  13.3 

The  cardiac  strength  (second  and  third  phases)  :  car- 
diac weakness  (first  and  fourth  phases)  ::  55.5:44.4. 

"Amer.  Jour,  Med.  Sci.,  1911,  CXLII,  336. 


Tests  of  Heart  Function  197 

Marked  increase  of  the  cardiac  weakness  factors  indi- 
cates cardiac  inefficiency. 

///.  Previously  to  Goodman  and  Howell's  work  many 
observers  18  have  recognized  that  the  duration  of  the 
second  phase  of  the  auscultatory  tones  indicated  cardiac 
strength.  A  considerable  reduction  of  its  normal  per- 
centage of  the  pulse  pressure  is  therefore  taken  as  a 
test  of  cardiac  insufficiency. 

IV.  The  Cardiac  Overload  Factor  of  Stone. — A 
paper  on  the  clinical  significance  of  high  and  low  pulse 
pressure  with  special  reference  to  cardiac  load  and 
overload  with  a  report  of  170  cases  was  presented  by 
Stone  at  the  meeting  of  the  American  Med.  Assn.  in 
1912.19 

The  ratio  of  the  pulse  pressure  to  the  diastolic  pres- 
sure representing  the  load  of  the  heart  has  since  been 
used  as  a  test  for  cardiac  efficiency.  Stone  says,  "the 
pulse  pressure  measures  the  energy  of  the  heart  in 
systole  in  excess  of  the  diastolic  pressure.  For  clinical 
purposes  it  represents  the  load  of  the  heart.  The 
myocardiac  load  may  therefore  be  expressed  by  the  frac- 

pulse  pressure 

tion  —. — — - •   and  under  normal  conditions  is 

diastolic  pressure 

approximately  50%."  Anything  in  excess  of  this  is  an 
overload.  The  average  load  in  these  cases  was  71,  an 
overload  of  21%.  Naturally  in  this  group  of  cases 
some  did  well  and  some  badly.  To  quote  again,  "judg- 
ing from  this  small  series  of  cases  it  would  appear  that 
when  the  overload  factor  exceeds  50%  the  patient  may 
be  in  danger  of  myocardial  exhaustion  at  any  time  of 
slight  overstrain.  As  a  rule  the  greater  the  overload 
the  greater  the  danger."  That  is  to  say,  an  overload 

18Forman,    Ztschr.    f.    diet,    und    physik.    Therap.,    XIII,    809; 
Fisher:  Deutsch.  med.  Wchnschr.,  1908,  XXXIV,  1141. 
19  Jour.  Amer.  Assn.,   1913,  LXI,  1256. 


198      Manual  of  Vital  Function  Testing  Methods 

of  50%  or  more  (the  pulse  pressure  equal  to  or  greater 
than  the  diastolic  pressure)  indicates  cardiac  insuf- 
ficiency of  a  considerable  degree  with  impending  de- 
compensation. Whereas  an  overload  of  25%  would 
seem  to  indicate  a  mild  degree  of  insufficiency. 

Swan  20  has  recently  published  a  study  of  the  above 
four  tests  with  a  series  of  observations  on  40  patho- 
logical cases.  His  conclusions  are  as  follows :  "It 
appears  to  me  legitimate  from  the  study  of  the  cases 
reported  to  conclude  that  all  four  of  these  factors  have 
some  value  in  determinkig  the  efficiency  of  the  myocar- 
dium. I  am  inclined  to  think' at  present  that  the  cardiac 
efficiency  factor  of  Tiegerstedt  and  the  percentage  of 
the  pulse  pressure  formed  by  the  second  phase  are  the 
most  important.  A  cardiac  efficiency  factor  of  40% 
or  over  would  seem  to  point  out  distinct  myocardial 
inefficiency.  A  second  phase  of  30%  or  under  would 
seem  to  indicate  the  same  condition.  The  CS  to  CW 
(cardiac  strength  to  cardiac  weakness)  ratio  is  less 
important  I  think  because  it  so  often  cannot  be  deter- 
mined and  again  because  a  small  second  phase  is  very 
frequently  made  up  by  a  large  third  phase.  On  the 
other  hand,  CS :  CW  ratio  in  which  the  CW  factor  is 
greater  than  the  CS  factor  is  indicative  of  disturbance 
of  the  myocardium,  functional  if  not  organic.  I  am  in- 
clined to  think  at  present  that  the  overload  factor  of 
Stone  is  indicative  more  of  peripheral  resistance  than  of 
myocardial  weakness.  A  cardiac  load  below  50%  as 
determined  by  this  method  giving  a  negative  overload 
may  have  some  significance,  but  it  will  require  further 
study  to  determine  its  nature." 

20  Archives   Int.   Med.,   1915,  XV,  269. 


Tests  of  Heart  Function  199 

#.     Rontgenoscopy   and   Rontgenography   as   Indices 
of  Cardiac  Function 

The  form,  position  and  movements  of  the  heart  as  a 
whole  and  its  different  chambers,  also  the  great  vessels 
at  its  base,  can  be  very  successfully  examined  by  the 
X-ray.  For  several  reasons  we  need  only  touch  upon 
this  interesting  and  remarkable  method  of  cardiac  ex- 
amination. In  the  first  place,  the  application  of  the 
X-ray  to  the  study  of  the  heart  concerns  more  par- 
ticularly the  examination  of  the  organ  from  a  diag- 
nostic and  anatomical  point  of  view.  From  this  stand- 
point it  constitutes  a  valuable  addition  to  the  older 
methods  of  heart  exploration.  It  cannot  be  said,  how- 
ever, that  a  Rontgen  ray  examination  sheds  much 
light  upon  the  question  of  cardiac  function.  Its  chief 
use  is  to  denote  changes  in  the  shape  of  the  organ, 
hypertrophy  and  dilatation  of  its  cavities,  aneurysm, 
pericardial  effusions,  etc.  By  orthodiagraphy,  the  posi- 
tion and  topography  of  the  heart  can  be  accurately 
delineated.  But  neither  ordinary  Rontgenoscopy  nor 
orthodiagraphy  of  the  heart  shed  much  light  upon  the 
problem  of  estimating  the  exact  efficiency  of  the  cardiac 
function. 

3.     Sphygmocardiography  and   Electrocardiography; 
Their  Relation  to  Cardiac  Functional  Capacity 

In  many  text  books  the  phrase,  functional  disease  of 
the  heart,  is  often  used  synonymously  for  pulse  irregu- 
larity. The  phrase,  cardiac  function,  is  used  in  an 
entirely  different  sense  here.  Cardiac  function,  so  far 
as  the  present  discussion  is  concerned,  relates  to  the 
capacity  of  the  heart  to  perform  its  work,  with  the 


200      Manual  of  Vital  Function  Testing  Methods 

adequate  maintenance  of  its  reserve.  An  irregularity 
of  the  cardiac  rhythm  does  not  necessarily  mean  any 
serious  deterioration  of  function.  For  example,  an 
individual  may  have  a  sinus  arhythmia  or  an  occasional 
premature  contraction  and  possess  an  absolutely 
normal  cardiac  reserve. 

On  the  other  hand,  the  discovery  of  certain  other 
types  of  irregular  rhythm  always  indicates  a  serious 
disturbance  of  heart  function.  The  presence  of  true 
heart  block,  for  example,  denotes  a  lesion  of  the  con- 
ducting system  and  hence  a  deterioration  of  function. 
The  same  may  be  said  of  auricular  fibrillation  and  to 
an  even  greater  extent  of  pulsus  alternans. 

But  the  detection  and  identification  of  irregularities 
in  the  cardiac  rhythm  is  a  part  of  the  general  semi- 
ological  investigation  of  that  organ  and  while  of  great 
importance  to  the  clinician  who  is  examining  a  case 
for  heart  disease,  does  not  properly  come  within  the 
scope  of  an  investigation  into  the  methods  of  estimating 
cardiac  function. 

The  study  of  cardiosphygmography  and  electro- 
cardiography  has  undergone  a  tremendous  develop- 
ment in  recent  years.  The  names  of  Marey,  Franck, 
Gaskell,  Engelmann,  Wenkebach,  Herring,  MacKenzie, 
Lewis,  Erlanger,  His  and  many  others  are  prominently 
identified  with  the  former  and  those  of  Waller,  Ein- 
thoven,  Kraus,  Nicolai,  Edclmann  and  others  with  the 
latter. 

The  recognition  of  nearly  all  the  varieties  of  arhyth- 
mia may  be  determined  by  the  skilled  clinician  without 
the  use  of  any  technical  apparatus.  Unfortunately, 
this  is  not  always  the  case  and  there  are  types  of  irregu- 
larity of  the  heart  rhythm  which  can  only  be  posi- 
tively recognized  by  the  use  of  some  form  of  instru- 
mental registration.  Pulsus  alternans  is  the  best  ex- 


Tests  of  Heart  Function  201 

ample  of  this  fact.  This  variety  of  arhythmia  cannot 
be  recognized  with  certainty  without  pulse  tracings. 
Its  importance  from  a  prognostic  standpoint,  as  Lewis 
points  out,  is  extremely  great.  This  fact  alone  will  al- 
ways make  the  polygraphic  study  of  the  pulse  a  matter 
of  necessity  in  all  cases  in  which  there  is  a  suspicion 
that  pulsus  alternans  may  be  present. 

The  ordinary  methods  of  examining  the  heart,  em- 
ployed in  clinical  diagnosis,  are  exceedingly  well  adapted 
to  disclose  diseases  of  the  organ.  By  inspection,  palpa- 
tion, percussion  and  auscultation,  properly  performed, 
not  only  can  it  be  determined  that  disease  of  the  heart 
is  present,  but  the  precise  location  and  often  the  nature 
of  the  lesion  can  be  made  out.  As  Cabot  has  well 
expressed  it,  "we  are  very  well  satisfied  with  the  ordi- 
nary methods  of  examination,  when  we  find  something 
such  as  valvular  disease,  obstructions,  accumulations 
and  degenerations.  But  in  many  cases  in  which  we 
fear  that  the  heart  is  diseased  and  its  functional  power 
diminished,  the  ordinary  methods  of  investigation  do 
not  show  anything.  Even  the  more  technical  and  re- 
fined instrumental  methods  are  negative  only  too  often 
in  such  cases.  The  heart  has  passed  a  good  physical 
examination  and  yet  may  be  insufficient.  We  desire  to 
know  what  the  heart  can  do,  what  is  the  condition  of 
its  reserve.  The  necessity  of  supplemental  methods 
becomes  manifest.  This  is  the  proper  field  for  experi- 
mental inquiry  into  the  heart  function.  It  is  here 
that  the  functional  tests  become  especially  useful.  We 
give  the  heart  some  work  to  do  and  see  how  it  reacts, 
how  fast  it  tires,  how  slowly  it  recuperates.  We  sub- 
ject the  patient  to  extra  effort  and  note  the  general 
symptoms  produced,  particularly  dyspnoea.  We  pro- 
ceed to  a  careful  analysis  of  the  history  of  our  patient 
with  respect  to  his  subjective  reaction  to  all  of  his 


202      Manual  of  Vital  Function  Testing  Methods 

environment.     Already  we  are  working  with  problems 
of  cardiac  function  in  a  fundamental  manner." 


General  Conclusions  as  to  Tests  for  Cardiac  Function 

Hirschfelder,  speaking  upon  the  importance  of  func- 
tional tests  or  studies  in  borderland  cases  between  func- 
tional sufficiency  and  cardiac  failure,  emphasizes  the 
importance  of  careful  observation  and  says :  "It  must 
be  admitted  that  in  order  to  be  decisive,  all  tests  have 
to  be  pushed  to  a  point  at  which  the  appearance,  sensa- 
tions and  signs  of  the  patient  are  in  themselves  per- 
fectly characteristic  of  cardiac  insufficiency  and  at 
which,  for  diagnostic  purposes,  a  little  common  sense 
observation  is  at  least  as  unambiguous  as  observation 
with  elaborate  apparatus.  This  does  not  mean  that 
exercise  tests  are  unimportant.  On  the  contrary,  they 
are  of  the  greatest  value  and  no  change  in  the  patient's 
mode  of  living  during  convalescence  or  during  after 
life  should  be  undertaken  without  them. 

"But  their  importance  depends  more  upon  the  care 
with  which  the  physician  watches  the  general  appear- 
ance and  condition  of  the  patient,  the  rapidity  with 
which  he  recovers  from  the  exercise,  his  general  condi- 
tion and  whether  nervousness,  irritability,  cough  or  in- 
somnia have  set  in  during  the  24  hours  following  it, 
than  in  the  numerical  changes  which  occur  at  the  mo- 
ment of  exercise.  The  symptoms  to  be  looked  for  as 
evidence  of  overwork  are  well  known.  These  are  subtler 
manifestations  resulting  from  smaller  changes  than  may 
be  detected  by  even  the  most  refined  observation  by 
mechanical  methods  and  which  are  less  easily  masked 
by  ambiguities. 

"Moreover,  it  must  be  realized  that  any  one  form 
of  exercise  furnishes  data  which  may  depend  as  much 


Tests  of  Heart  Function  203 

upon  the  condition  of  the  skeletal  muscles  as  upon  the 
heart.  The  blacksmith  with  a  diseased  heart  may  be 
able  to  do  more  work  than  the  bookkeeper  with  neuras- 
thenia and  yet  under  the  conditions  in  which  he  lives 
even  if  not  under  the  strength  test  arranged  for  the 
average  man,  the  blacksmith's  heart  may  be  failing. 
In  diagnosis,  prognosis  and  therapy  the  testing  of  func- 
tional insufficiency  is  a  matter  of  sociology  as  well  as 
physiology.  The  important  question  is  not  what  the 
person  can  do  in  a  gymnasium,  but  what  he  can  do 
and  what  he  cannot  do  in  everyday  life.  Each  man 
must  be  fit  for  his  own  mode  of  life  or  must  be  made 
to  change  it.  His  cardiac  power  must  be  studied  with 
reference  to  that  mode  of  life  rather  than  with  refer- 
ence to  a  rigid  scheme."  21 

21  Diseases  of  Heart  and  Aorta,  Phila.,  1913,  199. 


CHAPTER  V 
THE  DUCTLESS  GLANDS 

GENERAL    CONSIDERATIONS 

THE  clinical  examination  of  function  of  the  endoc- 
rinous  glands  is  a  subject  capable  of  great  future 
growth.  Only  the  first  steps  have  so  far  been  taken  in 
developing  this  mine  of  hidden  riches.  To  the  physi- 
ologist, pathologist  and  clinician  the  subject  offers  a 
fertile  and  tempting  field  of  investigation. 

In  the  following  account  of  the  functional  diagnosis 
of  the  endocrinopathies  but  little  can  be  given  of  the 
enormous  mass  of  experimental  material,  and,  as 
Barker  1  has  said,  "the  greater  mass  of  theories"  pro- 
pounded, concerning  the  physiology,  semiology,  pathol- 
ogy and  interrelations  of  the  glands  of  internal  secre- 
tion. These  subjects  with  complete  bibliographic  and 
historic  references  can  be  found  in  the  classical  works 
of  Biedl,2  Vincent,3  Falta4  Levi-Rothschild,5  Paton,6 
Sajous  7  and  others. 

In  these  great  works  little  or  nothing  can  be  found 
concerning  the  important  question  of  functional  diag- 
nosis. The  material  that  has  been  evolved  concerning 

Southern  Med.  Jour.,  1914,  VII,  1. 

2  Internal    Secretary    Organs,    London,    1913,    Bale    Danielsson 
(Trans,   from  German). 
8  Ductless  Glands,  London,  1912,  Arnold. 

4  Erkrankungen  der  Blutdriisen  Wien,  1913. 

5  Endocrinologie,  Paris,  1911,  Dion. 
"Internal  Secretions,   Phila.,   1911,  Davis. 

7  Regulators  of  Metabolism,  London,  1913,  Macmillan. 

204 


The  Ductless  Glands  205 

the  investigation  of  function  of  the  ductless  glands  or 
glands  of  internal  secretion  is  not  only  scant  but  scat- 
tered widely  in  the  literature  from  whence  so  far  as  we 
know  it  has  never  been  gathered.  Not  a  single  article 
devoted  to  the  general  question  of  the  functional  diag- 
nosis of  the  endocrine  glands  exists  in  the  whole  medical 
literature.  In  isolated  instances  where  the  subject  of 
functional  diagnosis  is  mentioned,  upon  investigation 
it  is  found  that  the  question  is  treated  upon  an  almost 
purely  semiological  basis.  The  semiological  method  of 
diagnosis  of  diseases  of  the  ductless  glands  has  there- 
fore reached  a  higher  degree  of  development  than  the 
functional  method,  among  clinicians  up  to  the  present 
time.  Notwithstanding  all  this,  it  is  admittedly  true 
that  the  clinician  is  much  in  need  of  functional  tests,  to 
enable  him  to  discover  the  various  endocrinopathies  in 
their  latent  stages,  or,  as  the  French  say,  in  the  forme 
fruste,  when  the  symptomatic  picture  may  be  incomplete 
or  confusing.  Therefore,  while  at  the  present  time  it 
cannot  be  said  that  satisfactory  chemical  or  biological 
functional  tests  have  been  discovered,  capable  of  dis- 
closing with  certainty  the  existence  of  latent  disease  of 
the  thyroid,  parathyroid,  thymus,  pituitary  or  adrenal 
organs,  nevertheless  some  advance  has  been  made  in  this 
direction  and  the  great  need  for  such  tests,  in  this  im- 
portant tho  subtle  field  of  clinical  medicine,  will  always 
constitute  a  sufficient  inspiration  for  further  discovery. 
As  will  be  developed,  the  principal  tests  which  have 
been  devised  up  to  the  present  time  with  the  object  of 
testing  endocrinous  function,  relate  to  the  thyroid 
gland  and  particularly  with  that  aspect  of  thyroidop- 
athy  which  is  connected  with  an  increased  activity  of 
the  gland.  Function  testing  of  the  adrenals  has  received 
some  attention  and  development.  The  other  ductless 
glands  remain  so  far  a  terra  incognita  to  the  functional 


206      Manual  of  Vital  Function  Testing  Methods 

method.  When  we  stop  to  consider  how  much  remains 
to  be  known  concerning  the  functions  and  interrelations 
of  the  glands  of  internal  secretions,  the  fact  will  not 
be  surprising  that  the  subject  of  functional  diagnosis 
of  their  diseases  has  not  received  a  greater  develop- 
ment. 

Regarding  the  ductless  glands  as  a  whole,  we  cannot 
fail  to  be  impressed  with  their  intimate  relation  to  the 
processes  of  body  metabolism.  The  organs  of  internal 
secretion  or  ductless  glands  (blutdriisen)  are  important 
regulators  of  metabolic  processes.  It  is  agreed  that  the 
pancreas  normally  inhibits  carbohydrate  metabolism 
and  that  on  the  other  hand  the  thyroid  and  suprarenals 
normally  increase  carbohydrate  metabolism.  The  thy- 
roid has  an  important  effect  upon  proteid  metabolism 
not  shared  by  the  other  glands.  Increased  function  of 
the  thyroid  is  accompanied  by  increased  proteid  metab- 
olism while  hypofunction  of  the  thyroid  produces  a  dim- 
inution of  proteid  exchanges.  The  parathyroids  and 
thymus  are  intimately  concerned  with  normal  calcium 
metabolism  but  their  exact  relation  to  this  process  is 
unknown.  The  gas  exchanges  of  the  organisms  are  also 
fundamentally  controlled  by  the  ductless  glands.  In 
hypcrthyrcosis  there  is  an  increase,  and  in  myxedema  a 
decrease,  of  the  oxygen  absorption  and  C02  exchange. 

These  facts  have  formed  the  basis  of  certain  experi- 
mental methods  of  determining  the  functional  capacity 
of  the  ductless  glands  and  were  it  not  for  the  fact  that 
the  performance  of  metabolic  experiments  is  so  com- 
plex and  requires  so  extensive  an  instrumental  equip- 
ment, the  examination  of  these  processes  as  aids  to  the 
functional  diagnosis  of  the  endocrinopathies  would  have 
a  much  wider  application. 


The  Ductless  Glands  207 

THE    THYROID    GLAND 

Tests  of  Functional  Activity 

Without  entering  debatable  ground,  it  may  be  con- 
fidently asserted  that  there  are  certain  facts  regarding 
the  physiology  and  pathology  of  the  thyroid  gland 
which  are  universally  admitted.  It  is  clear,  for  in- 
stance, that  the  thyroid  is  of  great  importance  in  the 
economy  of  the  human  organism,  and  that  certain 
lesions  of  this  gland  give  rise  to  symptoms  which  when 
they  are  outspoken  may  be  definitely  correlated  with 
thyroid  disease. 

However,  despite  all  the  work,  experimental  and 
clinical,  which  has  been  done  upon  this  gland,  there  is 
even  now  no  absolute  unanimity  of  opinion  of  the  pre- 
cise function  or  functions  of  the  thyroid.  The  thyroid 
function  is  probably  not  simple  but  complex.  As  in 
the  case  of  the  other  ductless  glands,  many  physicians 
feel  convinced  that  there  is  an  antitoxic  function  of  the 
thyroid,  which  consists  in  collecting  exogenous  iodine 
and  in  some  mysterious  and  unknown  way  neutralizing 
certain  hypothetical  products  of  intermediary  metab- 
olism. Naturally  this  idea  is  a  pure  speculation  and 
has  been  arrived  at  by  indirect  reasoning.  The  most 
usually  accepted  theory  of  thyroid  function  is,  how- 
ever, that  the  thyroid  manufactures  an  internal  secre- 
tion, possibly  an  iodine  proteid,  which  is  essential  to 
the  proper  growth  and  normal  metabolism  of  the  entire 
body.  Baumann  8  made  an  epochal  discovery  in  1895 
when  he  showed  that  the  thyroid  gland  contains  iodine. 
Although  speculation  and  investigation  have  since  been 
rife  in  respect  to  this  discovery,  its  precise  meaning 
is  yet  unknown. 

8Zeitsch.   f.  physiol.  Chem.,  1895,  XXI,  319. 


208      Manual  of  Vital  Function  Testing  Methods 

The  vast  amount  of  work  which  has  been  done  upon 
experimental  extirpation  of  the  thyroid  can  only  be 
mentioned.  If  the  thyroids  are  removed  from  young 
animals,  growth  is  retarded.  Total  extirpation  of  the 
thyroids  in  human  beings  is  well  known  to  be  followed 
by  serious  symptoms,  the  so-called  cachexia  strumipriva. 
If  the  individual  is  young  there  will  be  retarded  growth, 
faulty  ossification,  mental  and  metabolic  enfeeblement. 
Similar  symptoms  are  seen  in  children  with  congenital 
thyroid  aplasia.  In  human  beings  who  are  deprived  of 
their  thyroids,  a  phenomenon  appears  which  is  not  seen 
in  lower  animals,  namely  myxedema. 

Spontaneous  myxedema  also  occurs  in  the  adult 
human  being  as  a  result  of  thyroid  insufficiency — the 
so-called  Gull's  9  disease.  Murray  10  discovered  that 
the  administration  of  thyroid  extract  will  eliminate  the 
symptoms  of  myxedema. 

If  thyroid  substance  be  fed  to  normal  animals,  symp- 
toms will  develop  which  are  similar  to  those  that  occur 
in  Graves'  or  Bascdow's  disease  in  the  human  subject 
and  are  supposed  to  be  due  to  a  hyperthyreosis  or 
hyperthyroidization — in  other  words,  an  increase  of 
function  of  the  thyroid. 

This  brings  us  to  the  important  induction  that  in 
the  human  subject  we  may  have  two  different  or  rather 
two  opposite  pathological  states  to  consider  in  respect 
to  the  thyroid  gland  and  its  functions,  namely  A.  a 
hyperthyreosis  and  B.  a  hypothyrcosis.  In  the  well 
developed  state  these  two  symptom  groups  constitute 
definite  and  tangible  clinical  syndromes. 

A.  Hypcrf  unction  of  the  Thyroid  Gland. — To  the 
syndrome  of  hyperthyreosis,  the  name  of  Graves'  or 
Basedow's  disease  is  attached.  The  symptoms  of  hyper- 

9  Trans.  Clin.  Soc.,  London,  18T4,  VII,  180. 

10  Brit.   Med.   Jour.,   1891,   7.96. 


The  Ductless  Glands  209 

thyreosis  may  be  placed  in  the  following  categories :  1, 
enlargement  of  the  gland;  2,  signs  of  heightened  ex- 
citability of  the  vegetative  or  sympathetic  nervous 
system ;  3,  signs  of  secondary  or  concomitant  dis- 
turbances in  other  cndocrinous  glands ;  4,  symptoms 
of  profound  disturbance,  usually  of  excess  metabolism ; 

5,  a  variety  of  disorders  of  the  central  nervous  system ; 

6,  a   peculiar  picture   in   the   blood    (leucopenia   with 
lymphocytosis). 

Naturally  in  this  review  of  functional  diagnosis  we 
cannot  go  into  a  detailed  account  of  the  semiological 
data  which  might  be  collected  under  each  of  the  above 
headings.  It  is  interesting  to  observe  that  the  symp- 
toms of  Graves'  disease  which  come  under  the  category 
of  the  vegetative  nervous  system  involve  both  the  auto- 
nomic  and  sympathetic  portions  of  that  system.  The 
autonomic  and  sympathetic  innervations  are  both  in- 
volved to  a  certain  extent  in  every  case,  but  in  one,  the 
former,  and  in  another  case,  the  latter,  system  will  be 
predominantly  affected.  The  eye,  heart,  blood  vessels, 
skin,  digestive,  respiratory  and  urogenital  apparatus 
are  all  supplied  with  innervations  of  both  kinds,  usually 
reciprocally  or  antagonistically,  and  consequently  in 
Graves'  disease  there  are  symptoms  referable  to  disturb- 
ances in  sympathetic  or  autonomic  innervations  in  sev- 
eral or  in  all  these  different  organs.  We  shall  not  enu- 
merate all  the  various  symptoms  of  Graves'  disease, 
since  such  an  enumeration  will  be  readily  found  in  books 
or  articles  dealing  with  the  semiology  of  this  condition. 
Whenever  a  sufficient  number  of  these  symptoms  can  be 
found  in  a  given  case  the  diagnosis  of  Basedow's  disease 
can  be  readily  made  and  a  quantitative  idea  of  the  se- 
verity of  the  case  may  be  gained  by  the  actual  number 
or  the  seriousness  of  the  symptoms.  In  other  words, 
when  the  classical  semiology  of  Graves'  disease  is  pres- 


£10      Manual  of  Vital  Function  Testing  Methods 

ent,  naturally  no  functional  tests  will  be  needed. 

A  striking  phenomenon  of  Graves'  disease  is  the  ac- 
celeration of  all  the  metabolic  processes.  This  accelera- 
tion includes  the  total  combustion  in  calories,  the  pro- 
tein, carbohydrate,  fat  and  mineral  metabolism.  In 
states  of  hypothyroidism  the  opposite  condition  of  re- 
tardation of  metabolic  processes  occurs. 

Functional  tests  have  therefore  been  proposed  as  a 
criterion  of  the  existence  of  states  of  hyper-  or  hy- 
pothyreosis  on  the  basis  of  increased  or  diminished  oxy- 
gen consumption  and  protein,  carbohydrate,  fat  and 
mineral  metabolism. 

As  simpler  methods  of  determining  the  activity  of 
these  various  processes  are  developed  we  may  hope  that 
this  kind  of  investigation  will  gradually  enter  more  and 
more  into  the  diagnostic  armamentarium  of  the  clinician 
who  is  interested  in  measuring  the  functional  integrity 
of  the  thyroid.  But  as  was  said  before,  the  technical 
difficulties  which  have  so  far  usually  surrounded  the 
methods  of  determining  and  measuring  the  various 
processes  of  metabolism  have  prevented  their  general 
introduction  into  clinical  medicine. 

The  symptoms  of  Graves'  disease  which  are  refer- 
able to  concomitant  or  reciprocal  disturbance  of  func- 
tion of  the  other  endocrinous  glands  have  contributed 
somewhat  to  the  diagnosis  of  hyperthyreosis  from  a 
semiological  standpoint.  This  circumstance  we  shall 
not  attempt  to  develop.  But  from  the  standpoint  of 
functional  diagnosis  of  the  thyreopathies,  these  disturb- 
ances acquire  a  considerable  importance  since  they 
open  the  way,  though  indirectly,  to  the  development  of 
means  for  testing  the  functional  activity  of  the  thyroid. 
It  is  quite  generally  held  that  the  thyroid  and  the  pan- 
creas mutually  inhibit  one  another's  activity.  The 
pancreas  and  chromaffin  system  (adrenals)  are  likewise 


The  Ductless  Glands  211 

mutually  inhibitory.  The  thyroid  and  the  adrenals  ap- 
pear, however,  to  reciprocally  favor  each  other's  activ- 
ity, that  is,  an  under  function  of  one  leads  to  an  under 
function  of  the  other,  while  an  over  function  of  the  one 
will  lead  to  an  over  function  of  the  other.  This  is  the 
teaching  of  the  present  Vienna  school  of  endocrinolo- 
gists  represented  particularly  by  Eppinger,  Hess, 
Falta,  Rudinger,  and  others.  According  to  the  teaching 
of  this  school,  a  hyperthyroid  function  will  be  accom- 
panied by  an  insufficiency  of  pancreatic  function  (inter- 
nal secretion)  and  by  an  increased  activity  of  the 
chromaffin  or  adrenal  system.  Hypothyroidism,  on  the 
contrary,  will  be  followed  by  over  function  of  the  inter- 
nal secretion  of  the  pancreas  and  diminution  of  adrenal 
functional  activity. 

On  the  basis  of  these  hypotheses,  certain  tests  have 
been  devised  to  disclose  a  hyperfunction  of  the  thyroid 
gland.  One  of  these,  the  so-called  adrenalin-mydriasis 
test  of  Loewi,  is  used  to  disclose  on  the  one  hand  an 
insufficiency  of  the  internal  secretion  of  the  pancreas 
and  on  the  other  a  hyperthyreosis.  So  far  as  its  ap- 
plication to  the  investigation  of  pancreatic  insufficiency 
is  concerned,  the  test  has  already  been  described  (v.  s.) 
With  reference  to  the  second  application,  namely  that 
of  disclosing  a  hyperthyreosis,  details  will  be  later 
given.  Tests  founded  upon  the  existence  of  a  glyco- 
suria,  either  spontaneous  or  following  the  injection  of 
adrenalin,  will  be  considered  under  the  heading  Adrenal 
Glands. 

The  diagnosis  of  hyperthyroidism,  or  Graves'  disease, 
is  easy  in  typical  cases.  The  enlarged  thyroid,  the 
tachycardia,  the  disturbances  of  the  sympathetic 
nervous  system,  the  tremors,  the  mental  state,  the  ac- 
celerated metabolism  and  the  blood  findings  make  a 
definite  and  indubitable  diagnostic  picture. 


Manual  of  Vital  Ftvnction  Testing  Methods 

There  are,  however,  many  cases  which  elude  the  clini- 
cian because  they  are  atypical.  To  these  latent  or 
atypical  cases  the  French  have  given  the  expressive 
title  of  formes  frustes.  Barker  1X  has  warned  us  very 
properly  that  any  one  of  eight  different  symptoms 
should  make  the  clinician  suspicious  of  Graves'  disease. 
The  symptoms  are:  (1)  persistent  tachycardia  (pulse 
above  85);  (2)  rapid  emaciation  without  apparent 
cause;  (3)  excessive  sweating;  (4)  persistent  watery 
diarrhoea;  (5)  neurasthenic  and  psychasthenic  states; 
(6)  outspoken  lymphocytosis ;  (7)  fine  tremors  of  the 
fingers;  (8)  one  or  more  of  the  usual  ocular  symptoms 
of  the  disease,  namely  protrusio  bulbi  or  positive  Dal- 
rymple,12  von  Graefe,13  Moebius',14  Stellwag,15  Jelli- 
nek  16  and  Rosenbach  17  signs. 

Suppose,  however,  one  of  these  suspicious  signs  be 
present.  How  shall  it  be  determined  whether  or  not 
there  is  actually  present  a  condition  of  hyperthyroid- 
ism?  It  is  here  that  a  satisfactory  functional  test  would 
be  invaluable.  Frederich  Miiller  first  called  attention 
to  its  necessity  under  such  circumstances.  Several 
functional  tests  are  at  present  available  for  this  pur- 
pose. Unfortunately,  they  have  not  been  found  entirely 
adequate.  Nevertheless,  they  are  of  a  sufficient  degree 
of  assistance  to  warrant  their  retention  by  the  clinician, 
especially  as  they  form  an  important  nucleus  upon 
which  future  investigators  may  build  new  theories  and 
points  of  departure  for  renewed  attempts  at  explora- 
tion. Some  of  them  have  not  been  sufficiently  developed 
as  yet  to  allow  a  final  opinion  to  be  formed. 

The  tests  of  hypcrfunctional  activity  of  the  thyroid 
gland  are  as  follows : 

"Widened  eye  slit;  "lagging  upper  lid;  "insufficient  converg- 
enee;  "infrequent  incomplete  winking;  w  pigmentcd  eyelids; 
17  tremor  of  closed  lids. 


The  Ductless  Glands  213 

1.  Hypophysis  Test  of  Claude,  Baudouin,  and  Porak. 

2.  The  Adrenalin  Mydriasis  Test  of  Loewi. 

3.  Induction  of  Experimental  or  Artificial  Hyperthy- 

roidism  as  a  Functional  Test. 

4.  The  Aceto-Nitril  Test  of  Reid  Hunt. 

5.  Metabolic  Studies  in  the  Functional  Diagnosis  of 

Hyperthyroidism. 

6.  The  Complement  Fixation  Reaction  as  Functional 

Test  of  Hyperthyroidism. 

7.  The  Specific  Ferment  Reaction  of  Abderhalden,  as 

Functional  Test  of  Hyperthyroidism. 

1.      THE    HYPOPHYSIS-EXTRACT    TEST    FOR    HYPERTHYREO- 
SIS.        CLAUDE,     BAUDOUIN,     PORAK    TEST  18 

Recently  Claude,  Baudouin  and  Porak  have  published 
some  interesting  researches  upon  the  use  of  extract  of 
the  posterior  lobe  of  the  hypophysis,  in  disclosing  the 
presence  of  latent  hyperthyroidism. 

In  their  experiments  they  made  use  of  a  hypophyseal 
extract  of  posterior  lobe  of  such  strength  that  1  c.c.  of 
the  substance  to  be  injected  was  equivalent  to  1/2  of  a 
posterior  lobe  of  a  beef's  hypophysis.  This  they  say 
corresponds  to  .05  of  hypophysis  powder. 

This  extract  was  obtained  by  the  action  of  alcohol 
at  70°  upon  the  hypophysis  powder,  dried  and  freed 
from  fat.  The  alcohol  is  evaporated  and  the  residue  re- 
dissolved  in  normal  salt  solution.  They  also  employed 
occasionally  a  watery  extract,  obtaining  results  with 
the  latter  which  were  practically  similar  to  those  ob- 
tained from  the  former. 

They  found  that  subcutaneous  injections  of  both 
watery  and  alcoholic  extracts  of  hypophysis  produced 
a  marked  reaction,  pallor,  glycosuria  and  diarrhoea,  the 

18  Bull,  et  Mem.  Soc.  Med.  d.  Hop.  de  Par.,  1914,  XXX,  No. 
22,  1904. 


214      Manual  of  Vital  Function  Testvng  Methods 

greater  effects  being  produced  by  the  watery  solution 
and  accompanied  by  greater  pain.  The  alcoholic  ex- 
tract was  found  to  be  less  painful  and  the  pain  less 
lasting. 

When  a  quantity  of  alcoholic  extract  corresponding 
to  one  whole  lobe  (beef)  was  injected,  the  authors  noted 
complex  effects,  such  as  an  action  upon  smooth  muscle 
fiber,  a  cardiovascular  effect  and  an  action  on  nutrition. 
The  diuretic  effect  was  doubtful. 

The  action  on  nutrition  was  characterized  by  gly- 
cosuria,  the  cardiovascular  effect  consisted  of  accelera- 
tion of  the  heart.  In  these  complex  effects  of  the 
hypophysis  there  appears  to  be  an  excitation  of  the 
sympathetic  system  shown  by  the  cutaneous  vasocon- 
striction  and  the  glycosuria.  The  accelerator  fibers  of 
the  heart  being  likewise  of  sympathetic  origin,  one  would 
naturally  expect  to  find  acceleration  of  the  beat.  One 
would  also  expect  that  with  concomitant  constriction 
of  the  peripheral  vessels  that  the  blood  pressure  would 
rise.  This  phenomenon  did  not  appear.  The  blood 
pressure  remained  the  same  or  was  lowered.  The  au- 
thors attribute  this  to  a  depressing  effect  of  hypophysis 
extract  on  the  myocardium.  They  noted  occasionally  a 
galop  rhythm  following  the  injections.  With  normal 
individuals  the  authors  noted  acceleration  of  the  pulse. 

They  then  proceeded  to  experiment  upon  cases  of 
Graves'  disease.  The  patients  were  kept  under  observa- 
tion free  from  emotional  excitement  until  the  normal 
pulse  rate  was  accurately  determined.  Injections  of 
plain  salt  solution  were  tried  as  controls. 

Thirteen  typical  Basedowians  were  used  in  their  ex- 
periments. With  the  exception  of  the  cardiovascular 
effects  the  results  of  injections  did  not  differ  from 
those  of  normal  cases.  The  symptoms,  pallor, 
contraction  of  smooth  muscle  fiber  of  intestine 


The  Ductless  Glands  215 

and  uterus,  and  glycosuria,  the  latter  fairly  well 
marked,  were  noted  in  the  case  of  Graves'  disease. 
Alimentary  glycosuria  was  more  readily  provoked  after 
the  injections  than  before,  showing  a  diminution  of  the 
already  lowered  carbohydrate  tolerance.  The  cardio- 
vascular effects  of  the  injections  were  highly  significant. 
In  normal  subjects  the  pulse  becomes  accelerated.  The 
acceleration  commences  two  or  three  minutes  after  the 
injection.  It  reaches  a  maximum  in  10  or  15  minutes. 
Then  the  frequency  rapidly  diminishes  and  in  about  20 
minutes  the  pulse  is  normal. 

In  the  cases  of  Graves'  disease,  however,  the  results 
were  found  to  be  diametrically  opposite.  The  pulse 
which  is  accelerated  before  the  injection  of  hypophysis 
extract,  becomes  quickly  slowed.  In  one  of  these  cases 
the  pulse  dropped  42  beats.  Usually  the  diminution 
in  number  of  beats  is  much  less,  averaging  8  or  10.  The 
maximum  lowering  is  reached  in  about  2  minutes,  some- 
times 4  or  6  and  rarely  even  10.  The  bradycardia  is 
usually  ephemeral.  Usually  in  7  or  8  minutes  the 
pulse  becomes  fast  again.  Sometimes  it  was  found  to 
return  to  the  original  number  previous  to  the  injection. 
In  the  majority  of  instances,  however,  it  remains  not- 
ably beneath  this  point. 

It  would  appear  as  a  result  of  these  interesting  ex- 
periments that  extracts  of  the  hypophysis,  which  nor- 
mally produce  tachycardia,  bring  about  an  opposite 
effect,  namely,  bradycardia  in  case  of  Graves'  disease. 

The  authors  believe  that  the  extract  of  hypophysis 
contains  principles  which  simultaneously  excite  the 
terminations  of  both  sympathetic  and  vagus  fibers. 
This  is  the  only  explanation  of  the  complex  effects  of 
the  substance,  differing  from  those  of  adrenalin,  which 
is  a  pure  sympathetic  stimulant.  Adrenalin,  when  in- 
jected, causes  both  glycosuria  and  tachycardia,  but  it 


216      Manual  of  Vital  Function  Testing  Methods 

does  not  produce,  ordinarily,  pallor  of  the  skin,  nor 
contraction  of  intestine  and  uterus,  as  does  hypophysis. 
The  pneumogastric  is  generally  considered  the  nerve 
which  produces  intestinal  peristalsis.  Since  hypophysis 
produces  peristalsis,  it  must  stimulate  the  10th  pair. 

If  now  we  consider  the  effects  of  hypophysis  in 
Graves'  disease,  we  may  begin  by  admitting  that  in  this 
condition  there  is  a  general  state  of  erethism  or  hyper- 
excitation  of  the  entire  sympathetic  and  parasympa- 
thetic  (vagus-autonomic)  systems.  That  the  sympa- 
thetic is  excited  is  proved  by  the  exophthalmus,  glyco- 
suria  and  tachycardia.  On  the  contrary,  the  symptom 
diarrhoea  which  is  so  constant  and  characteristic  a 
symptom  in  Basedow's  disease  is  explained  by  Ep- 
pinger  and  Hess  and  others  on  the  theory  of  a  hyper- 
vagotonia. 

When  one  injects  into  a  Basedowian  an  extract  of 
hypophysis,  with  the  exception  of  the  pulse  rate,  the 
effects  are  generally  similar  to  those  obtained  upon  the 
normal  subject. 

The  heart  slowing  phenomenon,  however,  found  by 
Claude,  Baudouin  and  Porak,  in  Basedowians  following 
injections  of  hypophysis  extract  remains  to  be  ac- 
counted for.  The  authors  believe  that  the  slow- 
ing is  due  simply  to  stimulation  of  the  vagus 
nerve  or  10th  pair.  They  think  that  hypophysis 
extract  acts  on  the  cardiac  rhythm  of  the  non- 
Basedowian  by  stimulating  the  accelerator  sym- 
pathetic. In  the  Basedowian,  however,  there  is  al- 
ready a  tachycardia  which  is  due  to  the  continual  hyper- 
excitation  of  the  sympathetics.  These  nerves  being 
already  in  a  state  of  hyperexcitation  do  not  react  to 
hypophysis  extract.  The  terminations  of  the  vagus 
which  are  not  excited,  therefore,  feel  the  full  effect  of 
the  hypophysis  stimulation  and  the  heart  is  temporarily 


The  Ductless  Glands  217 

slowed  while  the  effect  lasts. 

Naturally,  the  authors  of  the  "hypophysis  test" 
mention  the  possibility  of  its  use  in  the  diagnosis  of 
latent  forms  of  Graves'  disease.  If  future  use  of  this 
test  should  corroborate  the  early  work  of  Claude,  Bau- 
douin  and  Porak  in  this  regard  the  "hypophysis  test" 
will  become  an  important  adjunct  to  the  functional 
diagnosis  of  the  hyperthyreopathies. 

With  respect  to  its  applicability  to  the  diagnosis  of 
the  forme  fruste  or  latent  form  of  Graves'  disease,  the 
authors  report  two  very  instructive  cases.  In  one  a 
woman  27  years  of  age,  of  neuropathic  taint,  suffering 
from  tachycardia,  dysmenorrhoea  and  slight  hand 
tremor  without  thyroid  enlargement,  the  injection  of 
1  c.c.  of  hypophysis  extract  produced  a  slight  increase 
in  the  rate  from  120  to  126  beats.  The  test  was  there- 
fore negative.  In  the  second  case,  that  of  a  nervous 
man  47  years  old,  with  a  tachycardia  (100  to  105 
pulsations)  with  slight  exophthalmia  and  slight  hand 
tremors,  with  no  apparent  thyroid  enlargement,  the  in- 
jection of  hypophysis  extract  slowed  the  pulse  from 
100  to  84  in  four  minutes.  The  test  was,  therefore, 
positive.  The  case  was  a  true  latent  form  of  Graves' 
disease,  that  is,  the  syndrome  of  hyperexcitation  of  the 
sympathetic  nervous  system  presented  by  the  patient 
was  truly  connected  with  and  due  to  a  hyperfunctiona- 
tion  of  the  thyroid  gland. 

The  authors  likewise  found,  which  may  be  mentioned 
for  its  scientific  interest  only,  that  in  cases  of  paroxys- 
mal tachycardia  the  test  is  negative,  as  would  on  a 
priori  grounds  be  expected.  In  this  condition  the 
pathogenesis  resides  not  in  the  sympathetic  nervous  sys- 
tem as  a  whole  nor  in  any  dysfunction  of  the  thyroid 
nor  any  other  endocrinopathy  but  in  changes  that  have 
taken  place  in  the  cardiac  musculature. 


218      Manual  of  Vital  Function  Testing  Methods 


2.       THE    ADRENALIN    MYDRIASIS    TEST    OF    LOEWI  19 

In  1907  Loewi  found  that  in  pancreatcctomized  ani- 
mals the  instillation  of  1-1000  solution  of  adrenalin  pro- 
duced marked  dilation  of  the  pupil.  In  human  beings 
with  diabetes  Loewi  found  the  same  effects.  In  30-60 
minutes  a  marked  dilation  occurred  in  diabetic  cases. 
The  application  of  this  phenomenon  to  the  detection  of 
pancreatic  insufficiency  has  already  been  mentioned. 

Loewi  also  made  a  simultaneous  observation  that  the 
instillation  of  1-1000  solution  of  adrenalin  into  the  con- 
junctional sac  in  cases  of  Basedow's  disease,  likewise 
resulted  in  dilation  and  proposed  the  method  as  a  test 
for  hyperfunction  of  the  thyroid  gland  on  the  ground 
that  the  internal  secretion  of  the  thyroid  and  suprare- 
nal are  synergistic,  both  acting  by  stimulating  the  sym- 
pathetic nervous  system.  In  cases  of  hyperthyroidism, 
the  sympathetic  nervous  system  is  in  a  state  of  increased 
irritability,  therefore  the  dilator  fibers  of  the  iris  which 
are  governed  by  sympathetic  nerves  respond  with  ab- 
normal alacrity  to  the  instillation  of  adrenalin.  Loewi's 
findings  were  corroborated  by  Falta  20  and  Zak.21 

Eppinger,  Falta  and  Rudinger,22  found  an  increased 
adrenalin  mydriasis  in  dogs  which  had  been  fed  with 
thyroid  extract.  In  depancreatized  and  thyroidectom- 
ized  animals  the  reaction  was  absent.  Eppinger  and 
Hess  23  also  reported  the  test  positive  in  Basedow's 
disease. 

The  interesting  and  extremely  simple  test  of  Loewi 

19Wien.  klin.  Wchnschr.,  20,  1907,  782;  Archiv  f.  exper.  Path, 
und  Pharm.,  59,  1908,  83. 

^Wien.  klin.  Wchnschr.,  20,  1907,  1559. 
"Verhandl.  d.  25  Kong.  f.  inner.  Med.,  1908,  392. 

22  Wien.  klin.  Wchnschr.,  21,  1908,  241. 

23  Verhandl.  des  26  Kong.  f.  inner.  Med.,  1909,  385. 


The  Ductless  Glands  219 

has  not  been  much  discussed  in  the  literature  in  recent 
years.  It  would  be  interesting  to  determine  whether  an 
increased  susceptibility  of  the  iris  sympathetic  as 
shown  by  mydriasis  exists  in  cases  of  latent  Graves' 
disease. 


3.  TEST  OF  EXPERIMENTAL  HYPERTHYROIDISM.  ADMIN- 
ISTRATION OF  THYROID  EXTRACT,  IODINE  AND  IODIDE  OF 
POTASSIUM  AS  A  MEANS  OF  DISCLOSING  FUNCTIONAL 
HYPERACTIVITY  OF  THE  THYROID 

Fr.  v.  Mueller,  who  criticized  the  metabolism  tests 
for  hyperthyroidism  as  being  too  complex,  suggested 
the  administration  of  iodine  as  a  means  of  disclosing 
hyperthyreosis.  But  apparently  Mueller  only  made 
the  general  suggestion  and  did  not  elaborate  any  speci- 
fied technique.  Since  no  one  else  has  done  so,  it  can- 
not be  said  that  an  "iodine  test"  exists  for  determining 
the  presence  of  a  latent  hyperthyroidism.  Patients 
with  hyperthyreosis  often  show  intolerance  to  iodine  by 
developing  emaciation  and  tachycardia,  after  its  admin- 
istration. 

Many  attempts  to  produce  experimental  thyroidism 
in  animals  by  feeding  thyroid  substance  have  been  made, 
and  there  seems  to  be  great  variation  in  the  resistance 
of  different  genera  to  thyroid  ingestion.  When  symp- 
toms appear  in  healthy  animals  the  most  constant  signs 
seem  to  be  emaciation  and  diarrhoea  (Carlson,24  Bal- 
let25). 

Kraus  and  Friedenthal  2G  found  that  the  intravenous 
injection  of  thyroid  juice  in  rabbits  also  produces  en- 
largement of  the  palpebral  fissure,  projection  of  eye- 

M  Prac.  Am.  Physiol.  Soc.,  1910-11,  XXVII,  p.  XIII. 
25  Limousin  Med.,  1896,  XX,  69. 
*  Berl.  klin.  Wchnschr.,  1908,  1709. 


Manual  of  Vital  Function  Testing  Methods 

balls  and  enlargement  of  the  pupil.  Other  authors  have 
succeeded  in  obtaining  similar  results. 

Since  the  introduction  of  thyroid  preparations  into 
clinical  medicine,  artificially  produced  hyperthyroidism 
has  been  observed  following  their  indiscriminate  admin- 
istration. The  continued  injection  of  thyroid  extract 
is  frequently  followed  by  symptoms  of  intolerance  such 
as  subjective  sensations  of  heat,  perspiration,  palpita- 
tion or  tachycardia  and  occasionally  glvcosuria,  all  of 
which  denote  hyperthyroidism. 

A  few  cases  have  been  reported  in  which  a  typical 
Graves  disease  syndrome  has  been  produced  by  the 
administration  of  thyroid  extract.  The  symptoms  dis- 
appeared after  a  suspension  of  the  treatment. 

It  is  a  well  known  fact  that  the  administration  of 
iodides  over  long  periods  to  cases  of  goitre  may  pro- 
duce symptoms  of  hyperthyroidism  (Kocher).27  To 
these  cases  the  name  iodine-Basedow  has  been  given. 

The  actual  administration  of  thyroid  extract,  iodine, 
and  iodide  of  potassium  to  disclose  a  latent  hyperthy- 
roidism or  Graves'  disease  is  not  to  be  recommended  as 
a  routine  procedure.  Most  writers  advise  against  the 
use  of  iodine,  iodides  or  thyroid  extract  in  any  case 
where  there  are  signs  of  emaciation  (Krecke  2S). 

Taking  all  the  above  facts  into  consideration,  it  will 
no  doubt  be  admitted  that  there  is  little,  if  any,  justi- 
fication for  the  administration  of  either  iodides,  iodine 
or  thyroid  extract  in  cases  of  suspected  Graves'  syn- 
drome with  a  view  of  thereby  developing  indubitable 
signs  of  the  disease.  It  cannot  be  said  to  be  justifiable 
under  any  circumstances  to  attempt  to  convert  a  latent 
or  doubtful  into  an  outspoken  case  of  Graves'  disease 
for  purposes  of  diagnosis. 

27  Verhandl.  d.  Dcutsch.  Ges.   f.  Chir.,  Berl.,  1910,  396. 

28  Munch,  mod.  Wchnschr.,  1911,  LVIII,  1601  and   1676. 


The  Ductless  Glands 

There  appears  to  be  among  many  medical  men  a 
lack  of  appreciation  of  the  dangers  which  are  attached 
to  the  indiscriminate  use  of  thyroid  extract  and  some 
surgeons  have  stated  that  many  cases  of  Graves'  dis- 
ease coming  under  their  observation  for  operation  give 
a  history  of  previous  ingestion  of  thyroid  extract. 
It  would  certainly  seem  rational  to  assume  that  noth- 
ing but  harm  can  come  from  such  a  practice. 

These  facts  are,  of  course,  well  known  and  appreci- 
ated by  a  very  large  majority  of  medical  men,  and  be- 
cause of  this  knowledge  no  systematic  attempt  has 
ever  been  made  to  develop  a  test  of  experimental  thy- 
roidism.  The  use  of  thyroid  extract,  iodides,  or  iodine 
for  such  a  purpose  can  only  be  mentioned  to  be  con- 
demned. 

4.       THE    ACETO-NITRIL,    TEST    OF    REID    HUNT 

It  was  in  the  effort  to  develop  a  quick  and  satisfac- 
tory method  for  comparing  the  physiological  activity 
of  different  thyroid  preparations  that  Hunt 29  dis- 
covered the  remarkable  fact  that  mice  when  fed  upon 
thyroids  develop  an  increased  resistance  to  aceto-nitril 
or  methyl  cyanide,  CH.CN.  This  substance  produces 
toxic  effects  chiefly  through  the  slow  liberation  of 
hydrocyanic  acid  in  the  body.  Since  thyroid  feeding 
does  not  alter  the  resistance  of  mice  to  hydrocyanic 
acid,  it  is  probable  that  its  action  so  far  as  aceto-nitril 
is  concerned,  is  exerted  upon  the  processes  by  which 
the  substance  is  decomposed  in  the  organism. 

Hunt  found  that  when  small  amounts  of  thyroid 
are  fed  to  mice  for  a  few  days  these  animals  acquire 

^Amer.  Jour,  of  Physiol.,  1899,  III;  Proc.  Soc.  Exp.  Biol.,  N. 
Y.,  1905,  Oct.  18;  Jour.  Biol.  Chem.,  I,  33,  Oct.,  1905;  Jour.  Amer. 
Med.  Assn.,  1906,  XLVII,  790;  Hygien.  Lab.  Bull.,  No.  47,  1907. 


222      Manual  of  Vital  Function  Testing  Methods 

a  markedly  increased  resistance  to  aceto-nitril.  This 
is  true  for  both  white  and  gray  mice,  although  most  of 
his  experiments  were  performed  upon  the  former  va- 
riety. 

A  mouse  which  had  received  thyroid  in  the  form 
of  cakes,  recovered  from  17  times  the  relative  amount 
of  aceto-nitril  fatal  to  a  control.  Another  mouse 
recovered  from  16  times  the  relative  dose  fatal  to  con- 
trols. A  third  mouse  recovered  from  11  times,  a  fourth 
from  6  times  and  a  fifth  from  2V2  times  the  fatal  dose 
to  controls. 

Hunt  suggested  this  reaction  as  a  delicate  test  for 
thyroid  substance.30  He  found  no  other  substance  with 
an  effect  upon  the  resistance  of  mice  to  aceto-nitril  at 
all  comparable  to  thyroid.  The  test  is  more  delicate 
than  any  chemical  test. 

Hunt  suggested  in  1907  that  this  method  is  adapted 
to  throw  light  on  the  question  as  to  whether  there  is 
an  excessive  amount  of  thyroid  secretion  in  the  blood 
in  cases  of  Graves'  disease.  He  applied  the  test  in  three 
cases.  In  one  of  these  the  blood  of  the  patient  had  a 
marked  effect  in  increasing  the  resistance  of  mice  to 
aceto-nitril,  indicating  thereby  an  excess  of  thyroid 
secretion.  In  a  second  case  the  results  were  doubtful 
and  in  a  third  case,  negative. 

Hunt  suggested  that  the  test  might  have  some  diag- 
nostic value  though  he  points  out  that  it  is  not  neces- 
sary to  assume  that  in  Graves'  disease  there  is  always 
an  excess  of  thyroid  secretion  present  in  the  blood  at 
all  times. 

To  carry  out  the  method,  he  suggested  that  the 
best  results  might  be  obtained  by  administering  to 
mice  1  or  2  c.c.  of  blood  made  up  with  meal  in  the 
form  of  cakes,  for  9  or  10  days  before  testing  with 

30  Jour.   Amer.  Mecl.   Assn.,  1907,  XLIX,  240. 


The  Ductless  Glands 

nitril.  Controls  are  indispensable.  One-fourth  of  a 
milligram  of  aceto-nitril  per  gram  of  body  weight  of 
mouse  may  be  fatal  to  a  normal  animal  in  a  few  hours. 
Hunt  used  doses  of  a  fraction  of  a  milligram,  one- 
fourth,  to  several  milligrams,  1,  2,  4,  in  his  experi- 
ments. 

Hunt  believed  as  a  result  of  his  researches  that  the 
activity  of  a  given  thyroid  preparation  or  substance 
is  parallel  with  its  iodine  content. 

The  test  suggested  by  Reid  Hunt  has  not  been 
extensively  developed.  His  findings  were,  however,  sub- 
stantially corroborated  by  several  authors,  among 
whom  may  be  mentioned  Trendelcnburg  in  1910, 31 
Ghedeni  in  1911.32 

Before  a  final  judgment  as  to  the  value  of  this  pro- 
cedure can  be  formed  it  will  be  necessary  to  determine 
the  resistance  of  mice  to  aceto-nitril  after  feeding  with 
the  blood  of  patients  with  Graves'  disease  in  a  large 
series  of  cases.  Also  experiments  should  be  done  to 
determine  the  resistance  of  mice  to  aceto-nitril  after 
feeding  with  normal  blood,  for  perhaps  the  test  is  so 
delicate  that  even  the  amounts  of  thyroid  secretions 
present  under  normal  circumstances  may  be  sufficient 
to  increase  the  animal's  resistance.  Of  course  the  vari- 
ations in  natural  resistance  of  the  animals  both  as 
regards  species  and  seasons  which  have  already  been 
demonstrated  as  well  as  the  possible  variations  in  the 
blood  content  of  thyroid  substance  even  under  normal 
circumstances  may  so  complicate  and  obscure  results 
that  the  test  may  be  found  impracticable. 

There  is,  however,  something  extremely  suggestive 
about  this  type  of  biological  experimentation  which 
makes  it  seem  probable  that  some  such  test  will  be 

31  Biochemische  Zeitschr.,  1910. 

S2Wien.  klin.  Wchnschr.,  1911,  XXIV,  736. 


Manual  of  Vital  Function  Testing  Methods 

discovered  in  the  future  of  real  value  in  the  diagnosis 
of  hyperthyreosis. 


5.       METABOLIC    STUDIES   AS    CRITERIA    OF 
HYPERTHYROIDISM 

In  Graves'  disease,  as  was  above  mentioned,  the 
metabolic  changes  are  increased.  Biedl  says  they  are 
so  characteristic  of  the  condition  as  to  constitute  an 
important  diagnostic  criterion.  The  metabolism  of 
Graves'  disease  is  accompanied  by  a  pretty  constant 
increase  in  the  expenditure  of  energy. 

The  respiratory  gas  interchange  shows  an  increase 
of  50%,  sometimes  70%  to  80%  in  the  amount  of  oxy- 
gen consumed,  according  to  Magnus-Levy,33  Salomon,34 
and  others. 

The  increased  production  of  heat  is  usually  accom- 
panied by  an  augmented  metabolism  of  albumen  and 
fats.  The  assimilation  of  carbohydrates  is  diminished 
in  Graves'  disease  and  it  is  for  this  reason  that  ali- 
mentary glycosuria  is  readily  produced. 

Kraus  was  the  first  to  suggest  that  determinations 
of  the  respiratory  metabolism  (increase  of  CO2  and  N), 
by  the  use  of  the  Zuntz-Geppert  apparatus  may  be  use- 
ful in  the  functional  diagnosis  of  latent  or  outspoken 
hyperthyroidism.  Fr.  v.  Mueller,  however,  observed 
that  the  method  is  too  complicated  for  practical  work. 

Studies  of  basal  metabolism  can  be  calculated  by 
indirect  calorimetry  from  the  oxygen  absorption  and 
the  respiratory  quotient,  using  a  Benedict  unit  appar- 
atus (mouthpiece  and  spiromcter).  At  least  three 
ten-minute  periods  are  run  and  the  average  taken  for 

33Bcrl.  klin.  \Vclmsrhr.,  1S95;  /cit.  f.  klin.  Mod.,  33,  1897;  Noor- 
di-m's  Handbook  d.  Path.  Stoffwi-chs.,  II,  3.52,  1907. 
31  Bcrl.  klin.  Wdmschr.,  1901. 


The  Ductless  Glands  225 

that  day's  basal  metabolism. 

Means  35  has  recently  reported  some  studies  of  basal 
metabolism  and  its  relation  to  body  surface  in  obesity, 
myxedema  and  pituitary  disease.  He  found  a  diminu- 
tion of  27%  below  normal  in  myxedema. 

The  emaciation  which  occurs  in  many  cases  of  Graves' 
disease  naturally  points  to  an  increased  katabolism. 
Kocher  found  reduction  in  weight  in  88%  of  his  cases. 
As  much  as  15  to  20  kgs.  may  be  lost  in  a  few 
months.  The  loss  of  weight  is  an  early  symptom.  The 
basic  cause  for  this  loss  in  weight  is  the  remarkable 
increase  in  the  caloric  production  which  occurs  in 
Graves'  disease.  By  using  the  Zuntz-Geppert  appa- 
ratus many  authors  have  made  the  demonstration  of 
increased  oxygen  consumption  and  increased  CO2  elim- 
ination. Magnus-Levy  and  Salomon  have  already  been 
mentioned. 

Experiments  have  also  been  made  in  the  Voit-Petten- 
kofer  apparatus  which  give  like  results.  The  increase 
of  caloric  production  as  was  before  stated  may  reach 
as  high  as  70%  or  more  above  normal.  In  some  cases 
(Magnus-Levy)  the  oxygen  consumption  has  been  found 
from  over  5  to  nearly  7  ccm.  per  kilogram  of  body 
weight.  Salomon  has  shown  that  these  metabolic  dis- 
turbances occur  and  may  be  demonstrated  in  the  latent 
cases. 

It  is  to  be  hoped  that  the  gradual  simplification  of 
methods  for  studying  metabolism  will  lead  to  practical 
clinical  results  which  will  undoubtedly  find  a  rich  field 
of  application  in  the  functional  diagnosis  of  thyroid 
diseases. 

^Proc.  Soc.  fr.  Exp.  Biol.  and  Med.,  1914,  XII,  1913. 


226      Manual  of  Vital  Function  Testing  Methods 

6.  APPLICATION  OF  THE  PRINCIPLE  OF  COMPLEMENT 
DEVIATION  TO  FUNCTIONAL  DIAGNOSIS  OF  HYPER- 
THYROIDISM.  MARINESCO-ROSEO  TEST 

Marinesco  36  in  1911  and  Roseo  3T  in  1912  appear  to 
have  been  the  first  to  suggest  that  in  Graves'  disease 
there  is  thrown  out  into  the  blood  serum  sufficient  thy- 
roid substance  (antigen)  to  give  rise  to  the  formation 
of  antibodies  (amboceptors)  in  the  patient's  blood. 
They  therefore  proposed  to  test  for  the  presence  of 
these  antibodies  in  the  blood  serum  of  suspected  cases  of 
Graves'  disease  by  means  of  an  antigen  prepared  from 
thyroid  tissue  removed  at  operation  from  an  outspoken 
case  of  Graves'  disease. 

Both  Marinesco  and  Roseo  have  studied  the  reaction 
of  fixation  of  alexine  (complement)  in  cases  of  Base- 
dow  disease  and  they  believe  that  the  positive  results 
obtained  proved  the  existence  of  true  specific  antibodies 
in  the  blood  in  this  condition.  This  test  may  in  future 
be  found  useful  from  the  standpoint  of  functional  diag- 
nosis. 

The  principle  of  the  complement  fixation  or  deviation 
test  depends,  as  is  well  known,  upon  the  observation 
that  the  injection  of  the  living  organism  with  bodies  of 
a  proteid  nature,  cells,  bacteria,  organ  extracts,  etc., 
results  in  the  formation  by  the  organism  of  certain  an- 
tagonistic bodies  called  antibodies.  Perhaps  these  anti- 
bodies are  ferments.  The  bodies  that  are  inoculated 
in  order  to  produce  antibodies  are  called  antigens. 
Some  antibodies  such  as  the  agglutinins  and  precipitins 
act  directly  on  the  specific  agent  or  antigen  which 
produces  them.  Other  antibodies,  such  as  cytolysins 
and  hcmolysins,  act  only  in  the  presence  of  a  third 

^Deutsch.  Zeits.   f.  Nervenheilk.,  1911,  XLI,  268. 
"Biochem  e  terap.  sper.,  Milan,  1912-13,  IV,  1. 


The  Ductless  Glands  227 

body,  which  is  always  present  in  blood  serum  or  tissue 
juices  to  which  the  name  complement  has  been  given. 
It  is  upon  this  state  of  facts  that  the  now  famous  Was- 
sermann  reaction  is  founded.  The  performance  of  the 
complement  fixation  test  particularly  in  the  diagnosis  of 
syphilis  has  become  a  part  of  the  routine  work  of  almost 
every  well  equipped  pathological  clinical  laboratory. 
Consequently  there  will  be  no  difficulty  in  a  well 
equipped  hospital  for  the  clinician  to  have  complement 
fixation  tests  performed. 

I  have  been  unable  to  obtain  the  exact  results  of 
Roseo's  work.  Marinesco's  38  observations  upon  the 
reaction  of  fixation  of  complement  included  two  series 
of  experiments.  In  the  first  he  used  an  aqueous  extract 
of  goitre  from  a  classical  case  of  Graves'  disease  as 
antigen  and  the  serum  of  the  same  patient  for  antibodies 
and  that  of  four  other  patients  with  the  same  disease. 
For  controls  he  used  the  serum  of  normal  persons.  The 
fixation  was  complete  in  the  first  case  whose  goitre 
furnished  the  antigen,  while  in  two  other  Basedowians 
there  was  incomplete  hemolysis,  and  in  a  fourth  the 
hemolysis  was  complete  as  in  a  normal  control.  An 
objection  which  may  be  urged  against  this  first  series  as 
pointed  out  by  Marinesco  is  that  he  did  not  have  at 
his  disposition  an  extract  of  normal  thyroid.  Later, 
with  the  assistance  of  Madame  Papazol,  he  repeated 
his  experiments,  this  time  making  an  examination  of 
23  sera,  and  using  different  extracts  from  the  thyroid 
gland  of  cases  of  Graves'  disease,  also  from  one  goitrous 
thyroid  and  one  normal  gland. 

The  extracts  were  prepared  in   the  usual  way   for 

ether  extracts.     Eight  grams  of  Basedow  goitre  were 

triturated  in  a  mortar  and  100  grams  of  ether  added, 

drop  by  drop.      The  mixture  was  put  in  a  sterilized 

38  Loco  citato. 


Manual  of  Vital  Function  Testing  Methods 

glass  and  placed  in  a  shaker.  After  shaking  and  filtra- 
tion, the  mixture  was  kept  for  48  hours  in  the  thermo- 
stat. After  the  evaporation  of  the  ether  a  little  car- 
bolated  water  was  added,  40  c.c.  for  8  grams  of  sub- 
stance. The  extract  was  then  again  shaken  and  filtered 
through  cloth.  The  prepared  extract  was  kept  on  ice 
in  a  dark  bottle.  The  alcoholic  extract  was  similarly 
prepared. 

In  the  two  cases  in  which  Marinesco  made  use  of  an 
autoextract  of  the  thyroid  from  cases  of  Graves'  dis- 
ease, the  prevention  of  hemolysis  was  complete.  He 
found  the  same  absolute  prevention  of  hemolysis  in  six 
other  cases  of  Graves'  disease  when  he  employed  thyroid 
tissues  obtained  from  other  Basedowians.  Aqueous,  al- 
coholic and  ethereal  extracts  appeared  to  act  about  the 
same,  but  sometimes  the  ether  extract  seemed  more 
active. 

In  most  cases  of  Graves'  disease  Marinesco  obtained 
either  a  total  absence  of  hemolysis  or  an  incomplete  or 
partial  one.  On  the  contrary,  the  serum  of  Graves' 
disease  cases  never  fixed  complement  in  the  presence  of 
normal  thyroid  body  or  extract  of  ordinary  goitre. 
He  got  the  same  results  when  he  used  serum  from  normal 
persons  and  Basedowian  antigen.  In  one  case,  however, 
Marinesco  and  Madame  Papazol  found  that  the  serum 
of  a  syphilitic  patient  gave  a  partial  hemolysis  with 
ether  and  alcoholic  extract  of  normal  thyroid.  Other 
authors  have  likewise  found  a  more  or  less  complete 
fixation  with  syphilitic  serum  in  the  presence  of  normal 
thyroid  extract.  Mueller,  of  Vienna,  in  a  personal  com- 
munication to  Marinesco  stated  that  in  a  case  of 
Graves'  disease  he  had  noted  a  fixation  of  complement 
in  the  presence  of  alcoholic  extract  of  heart. 

Marinesco  believes  that  his  experiments  tend  to  show 
the  presence  of  an  antigen  in  the  thyroid  gland  of  Base- 


The  Ductless  Glands  229 

dowians  and  that  the  reactions  of  fixation  which  he 
obtained  are  not  simply  due  to  an  increase  in  the  active 
substance  (internal  secretion)  of  the  thyroid  gland  but 
to  a  change  in  the  colloidal  state  of  this  substance,  due 
to  the  harmful  effects  of  a  pathogenic  agent.  Marines- 
co  calls  attention  to  the  difficulty  in  penetrating  more 
deeply  into  the  mechanism  of  his  fixation  reaction  since 
authors  in  general  are  by  no  means  in  accord  in  explain- 
ing the  mechanism  of  the  fixation  reaction  discovered 
by  Wassermann  in  the  serum  of  syphilis.  Some  authors 
like  Wassermann  himself,  seeing  in  the  reaction  the 
existence  of  true  specific  syphilitic  antibodies,  others  on 
the  contrary  considering  it  as  a  non-specific  physical 
chemical  phenomenon. 

The  practical  possibilities  for  functional  diagnosis, 
of  his  findings  are  believed  by  Marinesco  to  be  worthy 
of  mention. 

For  the  Marinesco-Roseo  test  it  will  of  course  be 
necessary  to  secure  thyroid  gland  tissue  at  the  time  of 
operation  in  a  case  of  outspoken  Graves'  disease. 

As  to  the  clinical  value  of  the  test  so  little  work  has 
been  done  by  investigators  subsequent  to  the  reports 
of  Marinesco  and  Roseo  that  no  definite  opinion  can 
be  formed  as  to  its  value.  This  will  become  a  matter 
for  future  investigation.  It  is  to  be  hoped  that  the  test 
will  be  carried  out  in  a  sufficient  number  of  outspoken 
cases  of  Basedow's  disease  to  determine  in  just  what 
percentage  it  will  be  positive.  If  the  findings  are  cor- 
roborated, the  test  should  be  applied  to  a  series  of  cases 
of  suspected  latent  hyperthyroidism.  At  the  present 
time  the  final  decision  as  to  its  value  remains  sub  judice. 


230      Manual  of  Vital  Function  Testing  Methods 

7.       SPECIFIC    FERMENT    TEST   OF   ABDERHALDEN    APPLIED 
TO    FUNCTIONAL   DIAGNOSIS    OF    THE   THYROID 

Lampe  39  has  attempted  to  apply  the  Abderhalden 
dialysis  method  to  the  study  of  the  blood  serum  of 
patients  with  Graves'  disease.  He  believes  that  in  the 
blood  serum  of  these  patients  ferments  exist  which  are 
specific  for  thyroid  tissue. 

This  method  has  never  been  applied  extensively  to 
the  functional  diagnosis  of  incipient  Graves'  disease 
since  its  introduction  by  Lampe.  The  technical  diffi- 
culties attached  to  the  carrying  out  of  Abderhalden's 
method  and  the  many  conflicting  results  obtained  in 
its  general  use  have  prevented  it  from  becoming  popu- 
lar in  clinical  practice.  Perhaps  in  the  future  when  the 
method  is  simplified  and  its  precise  limitations  defined, 
some  practical  results  may  be  hoped  for. 

Lampe  first  demonstrated  in  1913  that  normal  blood 
serum  obtained  from  healthy  individuals  does  not  con- 
tain any  ferments  capable  of  splitting  the  tissues  of  any 
of  the  organs. 

In  the  same  year  Lampe  and  Papazolu  40  examined 
the  effects  of  the  serum  from  cases  of  Graves'  disease 
to  determine  the  presence  or  absence  of  proteolytic  fer- 
ments specific  for  thyroid  tissue.  Lampe  thought  that 
by  the  results  of  the  dialysis  method  he  might  be  enabled 
to  throw  some  light  upon  the  question  as  to  whether  in 
Basedow's  disease  there  is  a  hyperthyroidism  or  a  dys- 
thyroidism.  He  does  not  mention  the  possibility  of 
employing  the  test  as  an  aid  towards  the  functional 
diagnosis  of  the  disease. 

Lampe  argued  that  if  in  Graves'  disease  there  is  an 
over-production  of  the  normal  thyroid  secretion,  there- 

""Miinch.  med.  Wchnschr.,  1913,  26. 
40  Munch,   med.  Wchnschr.,  1913,  28. 


The  Ductless  Glands  231 

fore  a  negative  result  of  the  Abderhalden  reaction 
(serum  -}-  thyroid  gland)  would  be  expected  because 
in  this  case  there  would  simply  be  the  introduction  into 
the  blood  of  a  purely  native  protein  only  in  increased 
amounts  and  consequently  no  development  of  ferments. 
If  on  the  contrary,  Graves'  disease  is  a  true  dysthyroid- 
ism,  if,  in  other  words,  the  thyroid  gland  in  Graves' 
disease  pours  into  the  blood  a  qualitatively  altered  pro- 
teid  secretion,  produced  by  the  pathological  changes 
in  the  gland,  then  this  secretion  acting  as  a  foreign 
proteid  would  be  expected  to  stimulate  the  produc- 
tion of  protective  ferments,  and  the  Abderhalden  reac- 
tion would  be  positive.  Lampe  hoped  also  to  be  able  to 
throw  some  light  by  his  method  upon  the  role  which  the 
thymus  plays  in  Graves'  disease. 

Lampe  and  Papazolu  experimented  with  the  serum 
from  Basedow  cases  upon  normal  thyroid  gland,  ex- 
ophthalmic goitre  gland,  cystic  and  parenchymatous 
goitre,  normal  thymus,  Basedow  thymus  and  several 
other  organs  and  tissues  as  ovary,  testicle,  kidney,  su- 
prarenal, pancreas,  etc.  In  their  article  they  give  the 
protocols  of  experiments  upon  the  serum  of  twenty-five 
cases  of  exophthalmic  goitre. 

In  all  cases  in  which  the  serum  from  the  Graves' 
disease  cases  was  allowed  to  act  upon  exophthalmic  goi- 
tre tissue,  the  tissue  was  digested.  In  very  few  cases 
only  was  the  reaction  positive  when  normal  thyroid 
tissue  was  used.  In  four  out  of  five  of  the  cystic  goitre 
products,  in  almost  all  thymus  and  ovarian  tissues  they 
found  the  reaction  positive.  With  all  other  substrate 
kidney,  liver,  pancreas,  etc.,  the  reaction  was  negative. 

Lampe  believes  that  his  researches  demonstrate  that 
in  Graves'  disease  there  is  a  true  dysthyroidism  and 
not  a  simple  hyperthyroidism. 

Principle  of  the  Abderhalden  Method. — The  basic 


232       Manual  of  Vital  Function  Testing  Methods 

principle  underlying  the  now  much  discussed  method 
of  Abderhalden  41  is  the  fact  that  albumen,  being  a 
colloid  does  not  diffuse  through  animal  membranes, 
while,  on  the  other  hand,  the  peptones,  which  are  the 
'first  products  of  its  decomposition,  are  diffusible.  If 
albumen  is  put  in  a  dialysing  tube  and  the  latter  placed 
in  water  no  albumen  appears  in  the  surrounding  fluid, 
even  after  a  considerable  lapse  of  time.  If  pepsin  and 
HC1  are  added  to  the  albumen  solution  peptones  are 
formed  and  will  appear  in  the  dialysate.  If  it  is  desired 
to  determine  whether  a  liquid  contains  any  proteolytic 
substance  or  ferments,  the  solution  may  be  placed  in  a 
dialysing  tube  and  peptone  will  appear  in  the  surround- 
ing media. 

In  this  way  blood  scrum,  cerebrospinal  fluid,  lymph, 
extracts  of  organs,  etc.,  may  be  tested. 

The  actual  carrying  out  of  the  Abderhalden  method 
is  extremely  difficult,  so  much  so  that  the  method  can- 
not be  used  in  the  ordinary  routine  of  clinical  work.  If 
the  method  is  to  be  tried  the  individual  who  proposes 
to  do  so  will  find  it  advantageous  to  consult  the  little 
work  of  Abderhalden  himself,  which  has  recently  been 
translated  and  to  which  reference  has  been  given. 

B.  Hypof  unction  of  the  Thyroid  Gland  (Myx- 
edematous  States). — The  best  concrete  example  of  the 
loss  of  function  of  the  thyroid  in  human  beings  is  met 
with  in  those  cases  in  which  the  whole  gland  has  been 
removed  by  operation  for  goitre. 

Reverdin 42  in  1882  was  the  first  to  describe  the 
results  of  goitre  extirpation.  In  1882  Kocher  43  pub- 
lished his  classical  report  on  the  same  condition.  The 

41  Defensive    Ferments    of    Animal    Organism,    Abderhalden;    tr. 
by  Gavronsky  and  Lanchester,  Lond.   Bale.  Co.,  1914. 
12  Rev.  Med.  de  le  Suisse  Rom.,  1882,  539. 
"Archiv  f.  klin.  Chir.,   1883,  XXIX. 


The  Ductless  Glands  233 

names  operative  myxedema  or  cachexia  strumipriva 
were  given  to  this  condition.  Inasmuch  as  the  thyroid 
gland  is  never  completely  excised  at  the  present  day  the 
subject  has  become  of  historical  interest  only. 

What  is  of  greater  practical  moment  is  the  fact 
that  symptoms  somewhat  similar  to  the  cachexia 
strumipriva  may  spontaneously  arise  in  adult  human 
beings  and  give  rise  to  the  now  well  known  but  only 
too  often  overlooked  syndrome  of  spontaneous  or 
idiopathic  myxedema  of  adults,  Gull's  disease.  The 
symptoms  are  produced  by  retrogressive  changes  in  the 
thyroid  gland.  Similarly  there  may  be  congenital 
states  of  hypothyroidism  and  infantile  types,  develop- 
ing after  birth,  the  so-called  sporadic  cretinism.  Fi- 
nally in  some  countries  a  condition  known  as  endemic 
cretinism  exists.  All  the  above  types  of  disease  are 
associated  with  a  diminution  of  function  of  the  thyroid 
gland. 

In  all  states  of  hypothyroidism  the  gland  itself  under- 
goes retrogressive  changes.  There  are  symptoms  refer- 
able to  the  skin  and  subcutaneous  tissues,  the  nervous 
system,  metabolism,  the  bones,  blood,  etc.  We  shall  not 
attempt  to  go  into  details  in  regard  to  the  semiology 
of  these  interesting  conditions. 

The  diagnosis  of  myxedematous  states  is  easy  in 
typical  cases  but  even  here  many  cases  are  overlooked 
by  the  practitioner.  In  latent  cases,  however,  the 
formes  frustes,  the  diagnosis  may  not  be  easy.  Some- 
times the  edema  is  taken  to  mean  Bright's  disease.  I 
have  seen  the  nervous  symptoms,  speech  difficulties  and 
gait  disturbance  ascribed  to  chronic  alcoholism.44 
Kocher  calls  the  latent  form  of  myxedema,  thyropenia. 
All  authors  call  attention  to  the  great  frequency  with 
which  it  is  overlooked. 

"Jour.  Am.  Med.  Assn.,  1915,  LX1V,  986. 


234      Manual  of  Vital  Function  Testing  Methods 

The  functional  diagnosis  of  thyropenia  is  intimately 
bound  up  with  the  treatment  for  there  is  but  one  diffi- 
culty and  that  is  to  suspect  the  disease.  Once  sus- 
pected there  is  one  infallible  test,  the  therapeutic 
test. 

Therapeutic  Test  for  Lowered  Functional  Activity  of 
the  Thyroid  Gland 

This  consists  in  commencing  the  administration  of 
thyroid  extract.  If  the  case  is  one  of  thyroid  insuffi- 
ciency the  symptoms  will  magically  disappear.  If  they 
are  not  entirely  gone  or  improved  in  two  weeks,  the  test 
is  negative.  The  condition  is  not  one  of  hypothyroid- 
ism. 

Thyroid  gland  is  best  given  in  the  form  of  tablets 
of  the  dried  gland.  The  tablets  contain  1%  to  5  grains 
(.1— .3  gm.)  of  desiccated  thyroid  gland.  Begin  by 
administering  a  small  dose  after  each  meal  or  less  often. 
The  patient  should  lie  down  for  twenty  minutes  after 
swallowing  the  tablet. 

The  dose  is  gradually  increased  until  6-10  tablets 
per  day  are  given,  care  being  taken  not  to  produce  rapid 
heart  action,  sweating,  diarrhoea  or  nervousness,  which 
are  symptoms  of  intolerance. 

From  a  therapeutic  standpoint,  which  point  we  can- 
not discuss  in  this  place,  it  is  well  known  that  the  ad- 
ministration of  thyroid  gland  in  states  of  hypothyroid- 
ism  must  be  kept  up  indefinitely,  for  so  soon  as  the 
treatment  is  stopped,  the  symptoms  will  invariably 
recur. 

THE    PARATHYROID    GLANDS 

The  first  person  to  specifically  describe  the  para- 
thyroids was  the  Swedish  anatomist,  Sandstrom,  in 


The  Ductless  Glands  235 

1880.  Gley  practically  rediscovered  them  in  1891. 
Since  the  latter  date  a  very  considerable  literature  has 
risen  upon  these  interesting  structures. 

Following  the  removal  of  two  or  more  of  the  four 
parathyroid  glands  in  the  human  subject,  tetany  comes 
on  in  from  2  to  5  days.  All  the  special  symptoms  of 
tetany  are  present.  Trousseau's,  Erb's,  Chvostek's  and 
Hoffmann's  signs,  with  irritability  of  the  nerves  of  spe- 
cial sense  and  the  sympathetic,  irregular  pulse,  arterial 
spasm,  angioneurotic  oedema,  spasm  of  gastrointestinal 
tract,  leucocytosis  and  disturbance  of  heat  regulation 
may  occur. 

After  incomplete  extirpation  or  temporary  injury 
of  the  glands,  milder  symptoms  occur  called  tetanoid  or 
subtetanic  hypoparathyreosis  (Halsted).  Sometimes 
the  sj'mptoms  are  latent  and  come  on  sometime  after 
injury  or  as  a  result  of  pregnancy,  trauma  or  infection. 
In  the  well-known  infantile  tetany  lesions  of  the  para- 
thyroids have  been  found. 

Other  convulsive  diseases  such  as  epilepsy,  paralysis 
agitans,  myoclonus,  myotonia  and  myasthenia  have 
been  supposed  to  be  due  to  disease  of  the  parathyroids, 
but  the  exact  facts  in  this  direction  are  as  yet  unknown. 

The  exact  relation  between  the  thyroids  and  para- 
thyroids is  not  known,  some  thinking  that  an  an- 
tagonism, others  that  a  synergism,  exists  between  the 
two. 

There  is  no  method  at  present  known  of  experimen- 
tally determining  the  functional  activity  of  the  para- 
thyroid glands. 

THE    THYMUS    GLAND 

The  function  of  the  thymus  is  as  yet  not  definitely 
known.  It  is  assumed  that  inasmuch  as  the  basic 


236      Manual  of  Vital  Function  Testing  Methods 

structure  of  the  thymus  is  that  of  lymphoid  tissue  in 
general,  that  there  is  a  related  function  between  the 
two,  in  other  words,  that  lymphocytes  and  eosinophiles 
are  formed  in  the  gland. 

There  are,  however,  present  in  the  thymus  structure 
some  epithelial  elments,  the  so-called  corpuscles  of 
Hassal.  What  their  function  may  be  is  quite  unknown. 
Many  believe  that  in  the  epithelial  cells  an  internal  se- 
cretion is  elaborated  which  has  to  do  with  the  develop- 
ment of  the  skeleton,  nervous  system,  sexual  apparatus 
and  general  metabolism. 

There  is  a  general  belief  that  a  reciprocal  action 
exists  between  the  thymus  and  testes,  since  castration 
delays  the  involution  of  the  thymus  while  removal  of 
the  thymus  causes  rapid  development  of  the  testes. 

The  fullest  development  of  the  thymus  is  reached 
at  the  end  of  the  second  year  of  life.  From  this  time 
on  to  puberty  it  gradually  atrophies  and  in  adults  is 
represented  only  by  a  small  mass  of  fibrous  tissue  and 
fat.  Occasionally,  however,  the  thymus  gland  persists 
or  undergoes  hypertrophy,  producing  symptoms  of 
tracheal  stenosis  with  attacks  of  laryngeal  stridor  or 
asthma,  and  sometimes  there  is  sudden  death,  the  so- 
called  mors  ihymica.  A  condition  known  as  the  status 
lymphaticus  may  gradually  develop  in  which  there  is 
more  or  less  anemia,  with  lymphocytosis,  together  with 
rachitic  and  gastrointestinal  symptoms. 

No  tests  have  so  far  been  devised  for  determining  the 
functional  activity  of  the  thymus.  The  diagnosis  of 
its  diseases  is  strictly  semiological  and  in  the  diagnosis, 
radiography  has  recently  been  of  considerable  assist- 
ance. 


The  Ductless  Glands  237 


THE  SUPRARENAL  GLANDS 

Our  more  intimate  knowledge  of  the  suprarenal 
glands  appears  to  date  from  the  year  1855,  when  Addi- 
son  published  his  famous  work  upon  the  disease  which 
bears  his  name,  though  they  have  been  known  since 
1564,  the  date  of  their  discovery  by  Eustachius. 

A  tremendous  amount  of  work  has  been  done  upon 
the  adrenals  by  investigators  in  the  past  half  century. 
Much  remains  to  be  learned  but  certain  facts  appear  to 
have  been  gained.  These  may  be  briefly  stated  as  fol- 
lows :  disease  of  the  glands  resulting  in  their  gradual 
atrophy  or  destruction  gives  rise  to  a  train  of  symp- 
toms characterized  chiefly  by  pigmentation  of  the  skin 
and  extreme  weakness,  i.  e.,  Addison's  disease.  Ex- 
tirpation in  animals  of  both  adrenals  is  an  extremely 
dangerous  operation  and  according  to  most  authori- 
ties leads  infallibly  to  death.  Extracts  obtained  from 
the  medullary  or  central  part  of  the  organ  are  toxic 
when  administered  to  animals,  among  the  symptoms 
being  glycosuria  and  arterial  degenerations.  The 
same  extracts  when  injected  intravenously  produce  a 
powerful  constriction  of  the  blood  vessels  with  rise  of 
the  blood  pressure  due  to  stimulation  of  the  sympa- 
thetic nervous  system. 

It  is  generally  accepted  by  clinicians  and  patholo- 
gists  that  the  adrenal  medulla  elaborates  an  internal 
secretion  and  that  adrenin  is  the  product  of  this  se- 
cretion. 

The  exact  function  of  the  adrenal  cortex  is  still  un- 
known. The  cortex  contains  a  considerable  quantity 
of  lipoid  and  cholinogen  substances,  the  presence  of 
which  has  given  rise  to  the  hypothesis  that  neutraliza- 
tion of  toxic  substances  is  effected  here. 

In  1894)  Oliver  and  Schafer  noted  that  extracts  of 


238      Manual  of  Vital  Function  Testing  Methods 

adrenal  medulla  produce  a  rise  of  blood  pressure.  In 
1897  and  1898  Furth  and  Abel  and  in  1901  Takamine 
and  Aldrich  succeeded  in  gradually  separating  and 
finally  isolating  in  pure  form  the  active  substance  of 
adrenal  medulla — adrenin. 

From  a  clinical  standpoint  the  functional  activity  of 
the  suprarenal  glands  may  be  considered  from  two 
points  of  view.  From  the  first  the  functional  activity 
of  the  glands  may  be  considered  to  be  lowered  and 
from  the  second  it  may  be  regarded  as  raised.  To 
the  first  condition,  the  name  hypoepinephria  or  hypo- 
adrcnalism  has  been  given,  and  to  the  second  hyper- 
epincphria  or  hyperadrenalism. 

In  our  brief  discussion  of  the  functional  examination 
of  the  suprarenal  glands  this  classification  will  be  found 
most  practical. 

We  may  properly  allude  here  again  to  the  antago- 
nism which  is  generally  considered  to  exist  between  the 
function  of  the  adrenals  (chromaffm  system)  and  the 
pancreas.  It  has  already  been  stated  that  the  adrenals 
and  thyroid  are  functional  synergists.  The  adrenal 
secretion  inhibits  carbohydrate  catabolism  and  raises 
blood  sugar,  while  the  pancreas  hormone  facilitates 
carbohydrate  catabolism  arid  lowers  blood  sugar.  The 
effect  then  of  lowering  the  adrenal  function  is  to  raise 
that  of  the  pancreas,  namely,  to  facilitate  carbohydrate 
catabolism  and  lower  blood  sugar  to  lead  to  hypogly- 
cemia,  oliguria  and  hence  absence  of  glycosuria.  The 
effect  of  raising  the  adrenal  function  will  be  to  inhibit 
carbohydrate  catabolism  and  to  raise  blood  sugar, 
hence  to  lead  to  hyperglycemia  diuresis  and  glycosuria. 

A.  Hypofunction  of  the  Suprarenal  Glands. — Sev- 
eral different  clinical  forms  of  hypoepinephria  or  low- 
ered adrenal  function  have  been  described,  but  few  of 


The  Ductless  Glands  239 

them  have  been  generally  recognized  by  clinicians  as 
separate  morbid  entities.  The  essential  features  of 
lowered  adrenal  function  appear  to  be  myasthenia  and 
hypotension.  The  systolic  blood  pressure  is  usually 
below  100  mm.  Other  features  justifying  a  suspicion 
of  hypoepinephria  are  hyperesthesias,  lumbar  pains, 
headache,  delirium,  coma,  digestive  disturbances  and 
sudden  death  without  previous  symptoms. 

The  chief  clinical  entity  which  is  recognized  as  be- 
ing accompanied  by  a  true  persistent  hypoadrenalism 
is  Addison's  disease. 

Addison's  disease,  first  described  by  Thomas  Addison 
in  1855,  is  a  chronic  condition  usually  appearing  in  the 
third  or  fourth  decade  of  life.  It  is  characterized 
clinically  by  pigmentation  of  the  skin  and  mucous 
membranes,  by  muscular  and  vascular  weakness,  dis- 
turbances of  the  gastrointestinal  tract  and  nervous 
system,  and  final  cachexia  and  death.  Anatomically 
it  is  accompanied  by  disease  of  both  adrenals,  usually 
a  caseous  tuberculosis.  We  shall  not  attempt  a  de- 
scription of  the  symptomatology  or  pathology  of  the 
disease. 

The  clinical  diagnosis  of  outspoken  cases  of  Addi- 
son's disease  is  sometimes  easy.  If  there  is  a  definite 
history  of  weakness,  vomiting,  constipation  and 
diarrhoea,  abdominal  and  lumbar  pains  and  there  is 
present  a  pigmentation  of  the  skin  and  mucous  mem- 
branes, and  when  pernicious  anaemia  and  a  few  other 
conditions  which  might  be  confused  with  it  can  be  ex- 
cluded, the  diagnosis  is  reasonably  certain.  In  Addi- 
son's disease  there  is  a  mononucleosis  and  a  hyper- 
eosinophilia,  in  the  blood. 

Before  the  pigmentation  occurs,  however,  the  diag- 
nosis is  extremely  difficult  or  impossible.  Latent  Ad- 
dison's disease  and  other  conditions  of  hypoepinephria 


240      Manual  of  Vital  Function  Testing  Methods 

can  only  be  disclosed  by  the  application  of  principles 
of  functional  diagnostic  methods.  Unfortunately,  the 
principles  upon  which  a  functional  investigation  might 
be  applied,  toward  the  elucidation  of  adrenal  dis- 
turbances, have  not  been  as  yet  developed  to  an  extent 
where  they  can  be  of  great  practical  assistance  to  the 
clinician. 

One  very  evident  possibility,  however,  suggests  it- 
self. If  states  of  hypoepinephria  are  accompanied 
by  diminished  function  of  the  adrenals,  there  must  be 
a  lessened  amount  of  the  substances  in  the  blood  which 
represent  the  gland's  activity.  There  is  no  practical 
way  at  present  to  make  use  of  such  an  hypothesis. 
Tests  for  increased  amounts  of  adrenalin  in  the  blood 
have  been  used  to  discover  the  opposite  state  of  hyper- 
adrenalism  and  these  tests  will  be  described  below. 

Eppinger,  Falta  and  Rudinger 45  showed  that  in 
cases  of  Addison's  disease  (hypoadrenalism)  the 
sugar  tolerance  is  remarkably  high.  Polak  46  was  un- 
able to  produce  a  glycosuria  with  2  mg.  doses  of 
adrenalin  in  a  case  of  Addison's  disease.  Similar  doses 
in  normal  persons  invariably  produce  glycosuria. 
Meyer  and  Kahn  corroborated  these  findings.  These 
facts  form  the  basis  for  the  application  of  various  kinds 
of  glycosuria  tests  to  the  functional  diagnosis  of 
hypoadrenalism. 


Tests  of  Increased  Sugar   Tolerance   as  Evidence  of 
Hypoadrenal  Function 

The   so-called   sugar   tests    have   been   described    at 
length  in  the  chapter  on  liver  function  testing.     (See 

45  See  Erkrankungen  der  Blutdriisen.     Falta.     Wien,  1913. 
"Wien.  klin.  Wchnschr.,  1909. 


The  Ductless  Glands  241 

page  14.)     In  every  case  of  suspected  adrenal  disease 
the  sugar  tolerance  should  be  investigated. 

B.  Hyperfunction  of  the  Suprarenal  Glands. — Just 
what  morbid  conditions  are  associated  with  or  produced 
by  hyperfunction  of  the  adrenals  is  by  no  means  clearly 
understood.  Certain  tumors  of  the  chromaffin  tissues 
have  been  held  to  produce  symptoms  connected  in  some 
way  with  hyperadrenalism.  The  question  as  to 
whether  other  conditions  besides  tumors  of  the  adrenals 
can  give  rise  to  states  of  hyperfunction  is  not  de- 
cided. 

A  number  of  pathological  states  of  the  organism 
have  at  one  time  or  another  been  claimed  to  owe  their 
origin  to  hyperfunction  of  the  suprarenal  glands  or 
chromaffin  tissues  generally.  A  school  of  pathologists 
in  France  has  for  a  long  time  endeavored  to  explain  the 
heightened  blood  pressure  of  nephritis  on  the  ground 
of  an  increased  function  of  the  suprarenal  glands. 
Further  than  this  it  has  been  held  that  the  arterio- 
sclerosis which  accompanies  the  circulatory  hypertonia 
is  the  result  of  hyperadrenal  function.  Finally  accord- 
ing to  some  pathologists  the  whole  process,  of  which 
circulatory  hypertonia  and  nephritis  form  important 
parts,  is  to  be  ascribed  to  a  primary  hyperplasia  of 
the  chromaffin  tissues. 

Certain  authors  have  contended  that  they  were  able 
in  such  conditions  to  demonstrate  by  means  of  the 
Ehrmann-Meltzer  reaction  (v.i.)  the  presence  of  ex- 
cessive amounts  of  adrenalin  in  the  blood. 

The  question  as  to  just  what  pathological  processes 
and  clinical  syndromes  are  to  be  held  related  to  hyper- 
adrenalism as  effect  to  cause,  is  a  question  almost 
entirely  open  and  undecided  at  the  present  time.  Fur- 
ther than  this  the  subject  of  functional  diagnosis  of 


24$      Manual  of  Vital  Function  Testing  Methods 

hyperactive  states  of  the  adrenal  glands  has  only  begun 
to  be  developed. 

The  principal  methods  suggested  are  two  in  number. 
The  first  depends  upon  the  generally  accepted  influence 
of  hyperadrenalism  upon  the  carbohydrate  metabolism. 
There  is  said  to  be  always  a  hyperglycemia.  Hence 
the  demonstration  of  an  excess  of  sugar  in  the  blood 
is  one  method  of  diagnosing  a  hyperepinephria,  pro- 
vided, of  course,  that  other  causes  of  hyperglycemia  can 
be  excluded.  There  is  unfortunately  no  simple  method 
of  making  the  test. 

The  second  class  of  functional  tests  for  hyperad- 
renalism depends  upon  the  demonstration  of  excess 
of  adrenalin  in  the  blood  and  the  production  of  gly- 
cosuria  following  the  injection  of  adrenalin. 

1.  Tests  for  Adrenalin  in  the  Blood  as  an  Evidence  of 
Hyperadrenalism.   The  Ehrmann-Melt  zer  Reaction 

It  has  long  been  known  that  intravenous  injection  of 
adrenalin  produces  dilatation  of  the  pupil.  This  fact 
has  been  utilized  as  a  test  for  adrenalin  in  various 
fluids,  as  blood  serum,  urine,  etc. 

Meltzer  and  Auer,47  Wessely 48  and  others  have 
found  that  when  adrenalin  is  applied  to  the  frog's  eye 
mydriasis  is  produced. 

Ehrmann  49  studied  this  phenomenon  and  suggested 
it  as  a  delicate  test  for  adrenalin.  He  found  that 
adrenalin  acts  upon  the  dilator  (sympathetic)  fibers 
of  the  iris  in  a  strength  of  1  to  20,000,000.  Dilatation 
of  the  pupil  of  the  frog's  bulbus  oculi  immersed  in  salt 
solution  occurs  when  excessively  minute  quantities  of 

"Centralbl.  f.  Physiol.,  1904,  XVIII,  316. 

48Zeitsch.  f.  Augenh.,  Aug.  13,  1905. 

49Archiv  f.  exper.  Path.  u.  Pharra.,  1905,  LIII,  96. 


The  Ductless  Glands 

adrenalin  are  present,  quantities  as  small  as  .000025 
mg.  Later  investigations  have  shown,  however,  that 
other  substances  in  blood  serum  will  produce  the  same 
reaction  and  therefore  the  practical  availability  of  the 
reaction  as  a  test  for  adrenalin  in  the  serum  is  vitiated. 


2.  Adrenalin  Glycosuria  as  a  Test  of  Hyper  function  of 
the  Chromaffin  System 

We  owe  to  Blum  50  the  discovery  that  the  hypodermic 
injection  of  adrenalin  will  occasionally  produce 
glycosuria.  The  reducing  substance  found  in  the  urine 
has  been  proved  to  be  glucose  and  there  is  always  a 
hyperglycemia  (Metzger51).  The  action  of  adrenalin 
in  thus  producing  a  hyperglycemia  is  due  to  its  well 
known  stimulating  effect  upon  the  sympathetic  nervous 
system  ( Underbill  52)  acting  upon  sugar  storing  organs 
and  causing  them  to  relinquish  their  supply  of  dextrose 
producing  substances  as  glycogen. 

Soon  after  Blum  made  this  discovery  the  interesting 
fact  was  tested  and  confirmed  in  many  directions.  It 
was  discovered  that  the  glycosuria  appears  after  the 
exhibition  of  extract  of  adrenal  substance  as  well  as 
after  that  of  its  active  principle,  adrenalin. 

Adrenalin  glycosuria  appears  after  comparatively 
small  doses  (.Ol-.l  mg. )  and  is  readily  provoked  by 
a  subcutaneous  injection.  The  injection  of  one  or  two 
milligrams  of  adrenalin  is  followed  in  half  an  hour  to 
two  hours  by  a  glycosuria  lasting  three  hours.  The 
glycosuria  is  always  accompanied  lay  a  hyperglycemia. 

50  Deutsch.  Arch,  f .  klin.  Med.,  1901,  LXXI,  146. 
01  Munch,  mecl.  Wchnschr.,  1902,  478. 
B2Amer.  Jour.  Physiol.,  1906-07,  XVII,  42. 


244      Manual  of  Vital  Function  Testing  Methods 

3.  Deviation  of  Complement  in  Functional  Diagnosis  of 
Suprarenal  Disease 

Polito  and  Corelli  53  have  attempted  to  apply  the 
complement  fixation  test  to  the  diagnosis  of  suprarenal 
gland  disease  (hyperf unction),  using  an  alcoholic  ex- 
tract of  suprarenal  gland  as  antigen.  Their  results 
were  indeterminate. 


THE    HYPOPHYSIS 

The  pituitary  gland  or  hypophysis,  as  is  well  known, 
is  composed  of  two  portions,  a  larger  anterior  epithelial, 
follicular,  glandular  portion  and  a  posterior  lobe  con- 
sisting of  connective  and  vascular  structures.  Between 
the  two  is  a  partly  glandular,  partly  vascular  por- 
tion, the  pars  intermedia.  The  whole  organ  is  con- 
tained in  a  bony  inclosure,  the  sella  turcica,  or  pituitary 
fossa  of  the  sphenoid  bone. 

Since  Marie  first  described  the  disease,  acromegaly, 
and  Rogowitch  noted  hypertrophy  of  the  pituitary 
after  thyroidectomy,  both  of  which  took  place  in  1886, 
a  very  large  literature  has  sprung  into  existence  con- 
cerning the  physiology  and  pathology  of  the  hypoph- 
ysis. 

The  deep  situation  of  this  interesting  organ  at  the 
base  of  the  brain  makes  experimental  investigation  very 
difficult.  The  embryological  and  histological  differ- 
ences between  the  anterior  and  posterior  lobe  of  the 
hypophysis,  made  it  extremely  probable  early  in  the 
history  of  these  investigations  that  a  different  func- 
tional activity  must  be  attributed  to  the  two  portions. 
68  La  Nouva  Riv.  Clin.  Terap.,  1911,  XIV,  482. 


The  Ductless  Glands  245 

In  this  respect  there  is  an  analogy  with  some  of  the 
other  ductless  glands. 

The  differentiation  of  the  two  systems  in  the  hypoph- 
ysis, from  the  standpoint  of  pathology,  is  especially 
difficult  because  of  the  confined  space  in  which  the  organ 
is  lodged,  making  it  almost  inevitable  that  disease  of 
one  portion  will  affect  the  other. 

The  name  of  Gushing  in  our  country  is  intimately 
associated  with  our  knowledge  of  the  hypophysis  on 
account  of  his  extensive  experimental  and  clinical  in- 
vestigations.54 

There  is  still  much  to  be  learned  concerning  the 
physiology  and  pathology  of  the  hypophysis.  Certain 
facts,  are,  however,  pretty  well  agreed  upon.  The 
pituitary  is  probably  essential  to  life,  i.  e.,  it  is  a  vital 
organ.  After  its  removal,  animals  soon  die  with  severe 
cachexia.  The  secretion  of  the  posterior  lobe  is  sup- 
posed to  gain  access  to  the  cerebrospinal  fluid  and  the 
general  circulation.  It  is  concerned  in  regulating 
metabolism,  particularly  that  of  carbohydrates.  It 
affects  also  the  growth  of  fat.  The  internal  secretion 
of  the  anterior  lobe  affects  the  processes  of  general 
metabolism  and  especially  growth. 

Oliver  and  Shafer  in  1895  55  discovered  that  ex- 
tracts of  the  pituitary  produce  when  injected  into  blood 
vessels,  a  rise  of  blood  pressure,  like  that  of  the  ad- 
renals. Three  years  later  Howell 56  discovered  that 
only  extracts  of  the  posterior  lobe  have  this  effect. 

As  with  the  thyroid  and  adrenals  there  is  the  same 
tendency  among  clinicians  to  regard  the  pathology 
of  the  hypophysis  as  being  manifested  by  states  of 
hyper-  and  hypo-function.  Acromegaly  or  Marie's 

54  The  Pituitary  Body  and  its  Disorders,  Phila.,  1912. 
05  Jour,  of  Physiol.,  1895,  18. 
56  Jour.    Exper.   Med.,    1898,   3. 


246      Manual  of  Vital  Function  Testing  Methods 

disease  is  regarded  as  a  typical  example  of  the  former, 
while  adiposo-genital  dystrophy  or  Frohlich's  disease 
is  looked  upon  as  an  equally  typical  example  of  the 
latter. 

In  our  very  brief  account  of  the  functional  diag- 
nosis of  the  pituitaropathies,  brief  because  so  little  of 
importance  has  been  accumulated  in  medical  literature, 
we  shall  consider  the  two  states,  opposite  and  distinct, 
producing  diametrically  opposite  effects  upon  the  or- 
ganism: hyperpituitarism  and  hypopituitarism. 

A.  States  of  Hyperpituitarism. — The  most  typical 
example  is  acromegaly  or  Marie's  disease,  first  described 
by  him  in  1886.57 

Acromegaly  is  a  chronic  disorder  characterized  by 
an  abnormal  increase  in  the  size  of  the  nose,  lips,  tongue, 
lower  jaw,  hands  and  feet,  by  hyperplastic  changes 
in  the  bones  and  soft  parts,  usually  accompanied  by 
considerable  enlargement  of  the  hypophysis  and  widen- 
ing of  the  sella  turcica.  Symptoms  of  increased  intra- 
cranial  pressure  often  occur.  The  vegetative  nervous 
system  is  in  a  state  of  hyperirritability.  The  most 
common  pathological  finding  is  adenoma  of  the  anterior 
part  of  the  hypophysis.  There  is  increase  of  function 
of  the  glandular  hypophysis,  a  true  hyperpituitarism. 

We  shall  not  enter  into  the  etiology  and  pathology 
or  into  the  detailed  account  of  the  general  symp- 
tomatology of  acromegaly.  As  to  the  general  diag- 
nosis of  the  disease  it  may  be  said  to  be  quite  easy  in 
outspoken  and  typical  cases.  It  is,  however,  difficult 
in  the  early  stages,  the  so-called  latent  period  of  the 
disease.  Acromegaly  must  be  differentiated  from  cer- 
tain diseases  which  may  partially  resemble  it.  Brain 
tumor,  arthritis  deformans,  Graves'  disease,  diabetes, 

"  Revue  de  Med.,  1886,  p.  298. 


The  Ductless  Glands  247 

progressive  muscular  atrophy,  have  all  been  diagnosed 
as  present  when  acromegaly  really  existed.58 

Combinations  of  acromegaly  with  Basedowian  or 
myxedematous  symptoms  sometimes  occur  in  the  earlier 
stages.  X-ray  examination  of  the  sella  turcica  (Oppen- 
heim)  is,  as  is  now  well  known,  of  extreme  diagnostic 
value. 

Two  methods  of  functionally  determining  the  exist- 
ence of  hyperpituitarism  have  been  suggested.  They 
are: 

1.  Demonstration  of  Disturbed  Metabolism,  as  shown 
by  increase  of  gas  exchange. 

2.  Demonstration    of    Alimentary    or    Spontaneous 
Glycosuria. 

1.  Demonstration  of  Metabolic  Disturbance  as  Shown 
by  Increase  of  Gas  Exchange  as  an  Aid  to  the  Func- 
tional Diagnosis  of  Hyperpituitarism 

Very  little  work  has  been  done  upon  the  study  of 
the  gas  exchanges  in  acromegaly.  That  which  has 
been  done  has  been  carried  out  with  the  Zuntz-Geppert 
apparatus.  Cases  have  been  examined  by  Magnus- 
Levy,  Salomon,  Bernstein  and  Falta. 

In  all,  there  are  seven  cases  reported,  in  which  de- 
tails are  given  as  to  the  clinical  facts  and  the  amount 
of  oxygen  consumption  and  carbon  dioxide  production 
in  ccm.  per  kilogram  per  minute.  The  figures  vary  for 
oxygen  from  5.19  ccm.  down  to  3.55  and  for  C02  from 
4.33  down  to  2.73.  Falta  states  that  the  results  of 
the  cases  so  far  investigated  do  not  demonstrate  an  in- 
evitable increase  in  gas  exchanges  in  acromegaly,  as  is 
the  case  in  hyperthyroidism. 

58  Modern  Med.,  Osler-McCrae,  1915,  IV,  813.    (Dock.) 


248      Manual  of  Vital  Function  Testing  Methods 

It  appears  to  be  the  opinion  of  Magnus-Levy  and 
Salomon  that  if  hyperpituitarism  is  uncomplicated  by 
disorder  of  other  glands  of  internal  secretion  (as  thy- 
roid) there  is  no  increase  in  the  gas  exchanges.  In 
this  opinion  Falta  59  concurred. 


2.  Demonstration  of  Spontaneous  and  Provocative 
Glycosuria  as  a  Functional  Test  for  Hyperpitui- 
tarism 

It  has  been  known  for  some  time  that  acromegaly  is 
often  accompanied  by  a  temporary  or  permanent  glyco- 
suria.  Marie,  who  first  described  the  disease,  called  at- 
tention to  this  fact.  Borchard,  from  a  study  of  176 
cases,  from  the  literature  found  spontaneous  glycosuria 
reported  in  63,  and  alimentary  glycosuria  in  8.  In  8 
cases  studied  by  Falta  there  was  spontaneous  or  ali- 
mentary glycosuria  in  5.  Glycosuria  appears  only  in 
the  early  stages  of  the  disease,  disappearing  towards 
the  end  with  the  beginning  of  cachexia. 

The  test  for  provocative  alimentary  glycosuria 
should  be  made  in  every  case  of  suspected  hyper- 
pituitarism. 

It  will  be  unnecessary  here  to  repeat  the  details  of 
technique  of  the  various  tests  for  provocative  gly- 
cosuria, since  they  have  been  fully  dealt  with  under  a 
previous  chapter.  The  four  tests  there  described  are 
(1)  the  Cane  Sugar  Test,  (2)  the  Glucose  Test,  (3) 
the  Levulose  Test,  (4)  the  Galactose  Test. 

The  Glucose  test  has  been  more  frequently  used  than 
the  others  in  testing  the  carbohydrate  powers  in  cases 
of  suspected  hyperpituitarism. 

59  Erkrankungen  der  BlutdrUsen,  Berl.,  1913,  p.  213. 


The  Ductless  Glands  249 

B.  States  of  Hypopituitarism. — This  state  is  typ- 
ically represented  in  the  so-called  hypophyseal  dys- 
trophy of  Frohlich,  or  dystrophia  adiposo-genitalis. 

Frohlich,60  in  1901,  first  emphasized  the  connection 
between  destructive  tumors  of  the  hypophysis  and 
the  occurrence  of  the  syndrome  which  bears  his  name 
and  whose  chief  characteristics  are  a  rapidly  developing 
adiposity,  infantilism  of  the  genitalia  and  myxedem- 
atous  degeneration  of  the  subcutaneous  tissues.  Many 
authors  have  since  reported  cases. 

The  opposite  conditions  with  respect  to  gas  ex- 
changes and  glycosuria  obtain  in  hypopituitarism  as 
compared  with  hyperpituitarism.  In  hypopituitarism, 
therefore,  the  same  functional  tests  are  applied  as  were 
discussed  above  under  acromegaly.  The  results,  how- 
ever, will  be  the  opposite.  The  gas  exchanges  will  be 
diminished  and  glycosuria,  both  spontaneous  and  pro- 
vocative, will  be  negative. 

""Wien.  klin.  Rundschau,  1901,  XLVII,  48. 


£<•£ 


INDEX 

PAGE 

Abderhalden's  test  in  hyperthyroidism 230 

Abderhalden's  method  and  liver  function 46 

Aceto-nitril  test  of  hyperthyroidism 221 

Adrinalinemia   and  hyperadrenalism 242 

Adrenalin  glycosuria  and  hyperadrenalism 243 

Adrenalin-mydriasis  test  of  hyperthyroidism 218 

Albarran's  method  of  testing  kidney  function 72 

Aminoaciduria,   experimental   provocative 33 

Aminoaciduria  and  liver  function 33 

Ammonia    nitrogen,    estimation    in    urine     (formalin 

method)    31 

Ammoniuria  experimental  provocative 32 

Antitoxic  liver  function 36 

Biliary   liver    function 47 

Bilirubinuria  and  liver  function 51 

Blood  coagulation  and  liver  function 41 

Blood  studies  and  renal  function 90 

Cammidge  reaction 162 

Cane  sugar  test  of  liver  function 15 

Cardiac  efficiency  factor  of  Tigerstedt 193 

Cardiac  overload  factor  of  Stone 197 

Cardiac  reflex  and  heart  function 187 

Cardiac  strength,  cardiac  weakness  ratio 194 

Cell  nuclei  test  of  pancreatic  function 148 

Claude  Baudouin,  Porak  test  of  hyperthyroidism.  .  .  213 

Coagulation  time  and  renal  function 104 

Coagulation  time,  test  for 41 

Complement-fixation  in  adrenal  disease 244 

Complement- fixation   test  of  hyperthyroidism 226 

251 


252  Index 

PAGE 

Cryoscopy  of  blood  and  renal  function 104 

Cryoscopy  of  urine  and  renal  function 86 

Diastase  in  feces  and  pancreatic  function 158 

Diastase  in  urine  and  kidney  function 85 

Diuretic  drug  tests  of  kidney  function 75 

Ehrlich's  urobilinogen  test 51 

Electric  conductivity  of  urine  and  kidney  function.  .  89 

i 

Fat  digestion  and  pancreatic  function 150 

Ferment  identification  and  pancreatic  function 153 

Fibrinogen  test  of  liver  function 42 

Fibrinolysis  test  of  liver  function 43 

Folin-Denis  method  of  estimating  incoagulable  nitro- 
gen in  blood 99 

Galactose  test  of  liver  function 18 

Gas  exchange  and  hyperpituitarism 247 

Ghedini's  test  of  liver  function 46 

Glucose  test  of  liver  function 16 

Glutoid  capsule  test  of  pancreatic  function 148 

Glycosuria  and  hyperpituitarism 248 

Glycosuria   and   pancreatic    function 166 

Goodpasture's  test  of  liver  function 43 

Graupner's  test  of  heart  function 175 

Gymnastic  test  of  heart  function 184 

Heart   function   tests 1 68 

Herz'  test  of  heart  function 181 

Hippuric  acid  test  of  renal  function 108 

Hohlveg-Meyer    method    of    estimating    incoagulable 

nitrogen  in  blood 99 

Hunt's  test  of  hyperthyroidism 221 

Hyperadrenalism     241 

Hyperpituitarism 246 

Hyperthyroidism^   experimental    219 

Hyperthyroidism  tests    for 208 


Index  253 

PAGE 

Hypoadrenalism    238 

Hypopituitarism    249 

Hypophysis  cerebri    244 

Hypophysis  test  of  hyperthyroidism 213 

Hypothyroidism    232 

Incoagulable  blood  nitrogen  and  renal  function 90 

Incoagulable  nitrogen  in  blood,  estimation  of 99 

Indicanuria  and  liver  function 38 

Indigo  carmine  test  of  renal  function 114 

Katzenstein's  test  of  heart  function 181 

Kidney   function   tests 64 

Kjeldahl's  nitrogen  method 28 

v.  Koranyi's  test  of  renal  function 86 

Lactose  test  of  renal  function 108 

Levulose  test  of  liver  function 16 

Lipase  estimation  in  blood 45 

Lipase  in  blood  and  liver  function 44 

Lipase  in  feces 160 

Liver  function  tests 13 

Loewi's  test  of  hyperthyroidism 218 

Loewi's  pupillary  test 165 

Lowenhart's  lipase  estimation  method 45 

Marshall's  method  of  urea  estimation  in  blood 94 

Marshall's  method  of  urea  estimation  in  urine 24 

Mendelsohn's  test  of  heart  function 179 

Metabolism  test  of  hyperthyroidism 224 

Methylene  blue  test  of  liver  function 36 

Methylene  blue  test  of  renal  function Ill 

Morris'  method  of  estimating  incoagulable   nitrogen 

in  blood    99 

Nitrogen  coefficient  and  liver  function 22 

Nitrogen  estimation  in  urine  (Kjeldahl's  method)  .  .  28 

Nitrogen  in  urine  and  kidney  function 80 


254  Index 

PAGE 

Pancreatic  function  tests 142 

Parathyroid  glands 234 

Phenolsulphonephthalein  test  of  renal  function 115 

Phenoltetrachlorphthalein  test  of  liver  function....  55 

Phloridzin  test  of  renal  function 107 

Polyuria  experimental,  and  kidney  function 72 

Potassium  iodide  test  of  renal  function 105 

Protein  digestion  tests  of  pancreatic  function 146 

Residual  nitrogen  and  liver  function 34 

Rest  nitrogen  in  blood  and  renal  function 90 

Roche's  test  of  liver   function 37 

Rontgenoscopy  and  cardiac  function 199 

Rowntree,  Geraghty  test  of  renal  function 115 

Rowntree,  Horwitz,  Bloomfield  test  of  liver  function  55 

Russian  test  of  heart  function 185 

Sahli's  test  of  pancreatic   function 148 

Sanguinopoietic   liver   function 40 

Schmidt's  test  of  pancreatic  function 148 

Schott's  test  of  heart  function 185 

Selig's  test  of  heart  function 173 

Sodium  chloride  elimination  and  cardiac  function.  .  .  188 

Sodium  chloride  elimination  and  renal  function 76 

Sodium  chloride  estimation 79 

Sphygmography  and  cardiac  function 199 

Sphygmomanometry  and  cardiac  function 188 

Staircase  test  of  heart  function 173 

Starch  digestion  and  pancreatic  function 153 

Stone's   cardiac  overload   factor 1 97 

Straus-Griinwald  test  of  kidney  function 75 

Sugar  tests  and  adrenal  function 240 

Sugar  tests  and  liver  function 14 

Suprarenal  glands    237 

Thymus  gland 237 

Thyroid    gland    207 

Tigerstedt's  cardiac  efficiency  factor 193 


Index  255 

PAGE 

Trypsin  estimate  in  stomach  contents 156 

Trypsin   estimate  in  stools 154 

Urea  in  blood  and  renal  function 90 

Urea  elimination  and  kidney  function 82 

Urea  elimination  and  liver  function 22 

Urea  estimation  in  urine  (Marshall's  method) 24 

Urea  provocative  test  of  McCaskey 83 

Ureagenetic  function  tests  of  liver 20 

Urinalysis  as  criterion  of  kidney  function 70 

Urinary  toxicity  and  renal  function 89 

Urobilinogen  test  of  liver  function 51 

Urobilinuria  and  liver  function.  .  •. 51 

Urobilinuria,  tests  for 54 

Urochrome  and  kidney  function 84 

Venous  pressure  test  of  heart  function 185 

Water  tests  of  kidney  function 75 

Whipple,  Horwitz  test  of  liver  function 42 

Whipple's  lipase  test  of  liver  function 44 

Work-velocity  ratio  and  cardiac  function 188 

Wright's  coagulation-time  method 41 


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